LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA. 



TREATMENT 

OF 

TYPHOID FEVER 



BY 



D. D. STEWART, M.D., 

Lecturer on Clinical Medicine in the Jefferson Medical College^ of 
Philadelphia; Physician to the Medical Dispensary of the 
Episcopal Hospital; formerly Attending Physician to 
St. Mary^s Hospital, and to St. Christopher 's Hos- 
pital for Children ; Fellow of the College 
of Physicians of Philadelphia. 




Copyrighted by 
GEORGE S. DAVIS. 
1893. 



CONTENTS. 



Pages 

Prophylaxis of Typhoid Fever, General and Special 1-12 
General Management of a Case of Typhoid Fever.. .13-48 
Specific and Antiseptic Treatment of Typhoid Fever. 49-71 
Treatment of Special Symptoms and Complications. .72-99 



TYPHOID FEVEB. 



PROPHYLAXIS OF TYPHOID FEVER, GENERAL 
AND SPECIAL 

Since it is now generally accepted that typhoid 
fever owes its origin to a pathogenic germ, and that 
the disease may be prevented and its dissemination 
obviated by attention to well established simple rules 
of hygiene, the comprehension of the latter is of prime 
importance to both practitioner and community. 

Typhoid fever is undoubtedly due to a micro- 
organism which obtains entrance into the body by 
way of the intestines, generally through the ingestion 
of water contaminated with the faecal discharge of a 
preceding case containing the germs of the disease. 
Of this there seems little question, though doubt yet 
exists whether the bacillus of Eberth is the only 
organism which has power to originate the disease. 
The recent investigations of Vaughan of Ann Arbor 
have led him, on good evidence, to believe the con- 
trary — that the Eberth germ, as found in the spleen 
and other organs in cases of fatally ending typhoid, 
is not a specific micro-organism, but a modified or 
involution form of a number of related bacilli, all of 
which differ in form, size, and methods of growth and 
reaction towards stains, and which produce identical 

I RRR 



poisons. He cites the view of Babes as the only 
tenable alternative, namely, that varieties of the 
Eberth bacillus exist; and the acceptance of this is 
tantamount to conceding his point, since it is practi- 
cally the same, whether the germs are varieties of 
one species or belong to related species. Prior to 
Vaughan's investigations, Rodet and Roux, from a 
careful study of the subject, arrived at the conclusion 
that the common colon bacillus, which Hueppe had 
previously recognized as possessing pathogenic prop- 
erties and as greatly resembling the Eberth germ, 
may become typhogenic under certain conditions 
outside the body — for instance, after a sojourn in 
cesspools and closets — and again entering the human 
organism, assume the character of the Eberth bacillus, 
and originate the disease. As to this aspect of the 
question, against that of those who hold both to the 
specificity and non-mutability of the Eberth germ 
and the possibility of related organisms under cer- 
tain conditions originating the disease, there is much 
that may be said. The question, however, cannot be 
discussed here.* Suffice it that the subject at present 
is so involved in doubt as to render the greatest care 
habitually necessary regarding the disposition of 
even non-typhoidal excreta, and to make it obliga- 

* See especially Comptes Rendus des Stances de la Soc.Biolog. , 
tome ii, No. 7, 18S0, and Vallet's paper, " Le Bacillus Coli 
Communis dans des Rapports avec le Bacille d'Eberth de 
l'Etiolog. de le Fievre Typh. — Paris, 1892. 



tory on health officers to do all in their power to 
guard against the possible pollution of drinking-water 
with faecal discharges, whether these be supposed to 
originate from a suspected case of typhoid or not — 
especially, too, since cases of unrecognized typhoid 
are of no uncommon occurrence in all communities. 
The unquestionable communicability of typhoid from 
the sick to the healthy, through the stools, makes dis- 
infection of these imperative. 

By far the most common mode of conveyance of 
typhoid fever is by the contamination of drinking- 
water with excreta from a preexisting case of the dis- 
ease. This, as Brouardel has remarked, is the mode 
of transmission of the disease ninety-nine times in 
every hundred. Other and less common modes of dis- 
semination are: by means of infected milk; through 
the soiled garments of typhoid cases; and more 
rarely, but especially in hot, dry seasons, through the 
transportation of the typhoidal poison in the dust of 
the atmosphere; the hands of the patient's attendants 
may also be the means of spreading the disease by 
coming in contact with articles of food or drink. 

In water the typhoid germ may retain its vitality 
for upwards of a month, though commonly it is de- 
stroyed in a shorter time by ordinary putrefactive 
bacteria. In ice, as Prudden has shown, the germ 
may lose none of its virulence even for months. In 
milk the germ is capable of quite rapid multiplication. 
It is especially in faecal matter and in poorly drained 



soil that the bacillus finds conditions favorable for 
its existence and multiplication; in these it may re- 
main virulent almost indefinitely. These briefly stated 
facts are of the utmost importance in indicating the 
necessity for thorough disinfection of typhoid dejecta 
in every case of the disease, which otherwise retains 
so much power for evil. A negligence in this direc- 
tion is unfortunately common, and has on numerous 
occasions resulted in deplorable epidemics of appar- 
ently mysterious origin until careful investigation has 
finally traced these to their true source, too often to 
but a single case of the disease in which gross negli- 
gence was shown in the disposition of the stools. 

All treatises on typhoid fever contain instances 
illustrative of this; only one need here be cited, that 
of Plymouth, Pa., in which, in the year 1885, lack of 
care in the disposition of the faecal discharge of a 
single case resulted in the development of 1,200 cases 
of typhoid fever, and some 130 deaths, in a population 
of but 8,000. The starting-point of the epidemic was 
a case contracted in a distant city. The patient, on 
going to Plymouth, occupied a house on a hillside 
which sloped toward the town, and but a short dis- 
tance from a mountain stream which at the time of 
the epidemic was the chief water-supply of the town. 
The case ran its course during midwinter and early 
spring, during which time the ground was frozen and 
snow-covered. The faecal evacuations were thrown, 
without any attempt at disinfection, upon the snow 



— 5 — 

toward the stream. On the occurrence of thaws and 
rains in March, the three months' accumulation was 
washed, by the melting snow, into the stream supply- 
ing the town. Shortly after, the epidemic began. 

Though water is much the most frequent source 
of transmission of typhoid fever, it must be borne in 
mind that milk not seldom plays the same role. Con- 
tamination of this fluid usually arises through the 
addition of infected water as a diluent, or through the 
use of water for cleansing the utensils, or, less com- 
monly, through contamination of the milk on expos- 
ure to infected dust. Numerous instances of epidem- 
ics through infected milk are now on record. Pepper, 
in his article on " Typhoid Fever" in the American 
Text-Book of Practice of Medicine, cites several re- 
cent ones, and still later ones are recorded by Sedg- 
wick and Chapin,* and by Dabney.f The epidemic 
investigated by Sedgwick and Chapin, which occurred 
in Summerville, Mass., it was found arose through the 
milk being infected from a well contaminated by 
typhoid dejecta. It was apparently the habit of the 
dealer to submerge the partly filled cans in the well 
for purposes of preservation. In some such manner, 
water from the well gained access to the milk. In 
this epidemic 150 cases occurred, with twenty-five 
deaths. There is no doubt that when an outbreak of 



* Boston Medical and Surgical Journal, vol. r2g, No. 20. 
\ Medical News, Dec. 2, 1893. 



typhoid fever occurs of undetermined origin, a care- 
ful scrutiny of the milk supply should be undertaken, 
coincidently with a search for the source of contam- 
ination through drinking-water. In referring to the 
epidemics occurring through infected milk studied by 
Sedgwick and Chapin and by Dabney, the Medical 
News (Dec. 9, 1893) remarks that if all water and all 
milk used for personal and domestic purposes were steril- 
ized, enteric fever would soon disappear. There is un- 
doubtedly much truth in this, for we actually know of 
no other sources than these for the origin of typhoid 
fever, beyond infection through ice or through vege- 
tables eaten uncooked. What a pity there cannot be 
some concerted action and efficient legislation in all 
cities in which typhoid is prevalent, towards its sup- 
pression, through the supervision of the water- and 
milk-supply! Doubtless it will come finally, but not 
until many epidemics have also come and gone, leav- 
ing desolation in their wake. 

Pettenkofer believes that the typhoid poison in 
the stools must undergo some alteration in the soil 
before it becomes infectious. It, however, seems im- 
possible that the poison of typhoid fever can be dis- 
seminated through sewer-gas alone. Pettenkofer 
fancies that the disease is always transmitted through 
the " ground-air." He found in certain localities, such 
as Munich, that typhoid fever was more prevalent 
when the ground-water was low. He believes this to 
be due to the fact that with the recession of the 



ground-water the air comes in contact with the germs 
and finally carries them into the atmosphere above- 
ground. 

The explanation now generally accepted of the 
actual cause of the greater prevalence of typhoid fever 
with low ground-water, is that contaminated foci, 
such as cesspools, are more thoroughly drained by 
wells, springs, and other sources of drinking-water 
supply, the level of water in which is below that of 
the source of contamination.* 

The foregoing facts give a slight idea of the 
prophylaxis necessary in preventing isolated cases or 
epidemics of typhoid fever, and a clue toward tracing 
them to their source after they have arisen. As al- 
most without exception the source is found to be con- 
taminated water or milk, it is obvious that in the 
event of an epidemic, apart from thorough attention 
to the disinfection of the excreta of the infected, a 



* Dr. H. B. Baker, of Michigan, confirms the opinion 
of Pettenkofer as to the greater prevalence of typhoid fever 
with low subsoil water, except in one important particular, 
and explains this relation more lucidly in the above manner. 
Baker (see Twelfth Annual Report of the Secretary of State 
Board of Health of Michigan, 1889) found that the rise and 
fall of the typhoid curve are in inverse ratio to that of the 
subsoil water in all seasons, save in winter, when the ground is 
deeply frozen. Then, of course, permeation of the soil by the 
infecting material is quite impossible, and contamination of 
drinking-water supply does not occur. 



rigid scrutiny as to the origin of the disease through 
the water- or milk-supply should be made. 

If the drinking-water or milk be suspected, 
another source of supply should be obtained if possi- 
ble. Should this be impracticable as regards milk, it 
will be better to cease for a time its use, or at least to 
see that that consumed is most thoroughly boiled. If 
a second water-supply cannot be obtained, the drink- 
ing-water used should be first filtered and subse- 
quently boiled before it is drunk. For culinary pur- 
poses thorough boiling is alone necessary. No filter- 
ing material now in use can be said to deliver water 
germ free for any length of time, not even the un- 
glazed porcelain of the Chamberlain-Pasteur filter. 
This last, however, is so arranged that the filtering 
tubes of porcelain can be readily cleansed or sterilized 
as repeatedly as seems necessary, by boiling.f For 
this reason it is the best of the various household 
filters sold. The spongy-iron and porous stone rank 
next, though, apart from cleansing the surfaces, 
sterilization of these is not so readily accomplished, 
if indeed it can be done at all. Filters into whose 
composition charcoal enters, it is needless to state, 
rather increase the danger than diminish it after the 
first day or two's employment. 

As practically the only danger of typhoid con- 

f This, when there is serious question regarding con- 
tamination of water, should be done every two or three days, 
if the water is not boiled subsequent to filtration. 



— 9 — 

tagion arises through the stools, the disinfection 
of these alone of all the excretions need engage 
the physician's attention. By far the best disin- 
fectant, as regards inexpensiveness, efficiency and 
practicability, is lime, either the milk or the solu- 
tion of the chloride. Of milk of lime, a powder 
of freshly burned and slaked lime is stirred in 
twice its bulk of water, and the mixture, in volume 
somewhat greater than the stool to be disinfected, is 
added to the latter in the vessel.* This, thoroughly 
mixed with the stool, is sufficient to destroy the in- 
fecting principle in about half an hour. Or, if chloride 
of lime is preferred, a specimen containing at least 
25 per cent, of available chlorine should be obtained. 
A solution of this in the proportion of four ounces to 
the gallon is made, and about a quart used for the 
disinfection of each stool. One or the other of these 
preparations of lime, in point of efficiency and inex- 
pensiveness unequaled, should be used in preference 
to all other disinfectants; they are as efficient in de- 
stroying the infecting principle of cholera as that of 
typhoid fever. In each case the stool must be thoroughly 
broken up and incorporated by means of a stick with the 
lime, and allowed to stand before throwing into the water- 

*F. P. Henry (Hare's System of Therapeutics, article 
"Typhoid Fever") states that he regards it sufficient to 
direct that slaked lime be mixed in an earthen or wooden 
vessel with enough water to make a thick whitewash. This 
is then added to the stool in the above manner. 



— 10 



closet) in the first instance a half -hour ^ and in the second 
at least one hour. Other disinfectants much used, 
such as corrosive sublimate, carbolic acid, the mineral 
acids (sulphuric or hydrochloric), copper sulphate, 
zinc chloride, or weak solutions of chlorinated soda, 
and the proprietary so-styled disinfectants — often so 
only in name — are not to be recommended. HgCl 2 , 
even in acid solution, is a poor disinfectant for faeces; 
in proportion of even 1:500, thorough disinfection 
requires at least six hours through contact — and even 
in this time, should the stools contain blood, its 
efficiency is doubtful. It, like the mineral acids — 
which are recommended by some as efficient, used 
diluted with equal parts of water— is very destructive 
to plumbing. Carbolic acid, unfortunately still highly 
recommended by systematic writers, and largely used, 
even in 5-per-cent. solution requires for efficiency at 
least tw T enty-four hours' contact — so that is out of the 
question as a practicable disinfectant. The other 
agents mentioned, save the proprietary articles, will, 
in the strengths usually employed, if the contact is very 
prolonged, destroy the bacilli, but do not affect their 
spores. The costly proprietary preparations are, so 
far as is known, without effect even upon the germs 
themselves. 

Even after thorough disinfection the stools should 
not be emptied upon the surface of the ground; and 
if they are buried, the situation should be remote 
from the source of drinking supply. Faeces must never 



be buried undisinfected, even in the rural districts. 
What is generally recognized as the typhoid germ 
possesses extraordinary vitality in the faeces and in 
the soil. By experiment it has been shown that 
typhoid bacilli multiply even at the depth of three 
meters below the surface. They, moreover, possess 
great power of penetrating the soil, and have been 
known to pass many hundred feet beneath a moun- 
tain and infect a spring at its base.* 

Disinfection of bed and body linen is, of course,, 
essential, as these are likely to become infected from 
the faecal discharges. The mattress of the sick-bed 
should always be protected by a rubber sheet placed 
immediately over it. Bed and body linen should be 
changed daily, or immediately if noticeably soiled. It 
is recommended by Fitz, quoted by Osier, that in 
hospital work and, if possible, in private practice, all 
changed linen, bath-towels, rubber sheets, and covers 
be immediately wrapped in a sheet soaked in carbolic 
acid (1:40), and removed to the rinse-house as soon 
as possible, to be there soaked for some hours in car- 
bolic acid (1:40). The linens are then boiled for a 
half-hour, and washed with soft soap. The rubber 
sheets and covers are to be rinsed in cold water, 
dried, and aired for eight hours. The bed-spreads 
and blankets are also to be aired for eight hours daily. 
After the patient's discharge from the hospital the 



* Billings: American Text-Book of Practice, p. 31. 



mattresses are to be aired daily for a week. The 
bedstead is to be washed in corrosive sublimate 
(i: iooo). 

The hands of the nurse, not neglecting the 
nails, should be thoroughly cleansed with hot water 
and soap and subsequently washed with disin- 
fectant solution, especially before eating after atten- 
tion to the patient at stool. The nurse should also 
rinse the mouth well with a disinfectant solution, 
such as permanganate of potash or chlorinated soda. 
When the patient's temperature is taken by the mouth 
or rectum, the thermometer should of course always 
be thoroughly disinfected by being washed is a 1:500 
HgCl 3 solution, or in a 10-per-cent. carbolic acid 
or strong chlorinated soda solution. 



GENERAL MANAGEMENT OF A CASE OF 
TYPHOID FEVER. 



Careful nursing is the one great essential. The 
case should be put in the hands of a careful nurse, to 
whom specific directions must be given, if necessary 
in writing, as to its management, even if the nurse be 
a trained one. Unless personally acquainted with her 
qualifications, the physician should himself at first 
superintend disinfection of discharges and the tech- 
nique of baths, and had better give instructions in 
writing as to the administration of nourishment and 
the like. 

The sick-room should be large, divested of all 
unnecessary trappings, and capable of being always 
well ventilated, with the bed so placed or screened 
that freedom from strong draughts is assured, though 
an abundance of fresh air is habitually admitted. Little 
danger to the patient from draughts exists while fever 
is present; yet, as Pepper justly observes, when reces- 
sions in the fever occur, with relaxation of the sur- 
face, congestions and increased catarrhal irritation 
may be readily induced by too great exposure. The 
room temperature should be maintained at about 
65 0 F., and if in hot seasons it rises much above this 
it may be cooled by exposure of a large block of ice 
in a tub, as is recommended by Marston. 

The bed must not be too wide, and should be so 



— 14 — 

placed that it may be approached from both sides by 
the attendant. The bed should be comfortable, but, 
whatever the patient has been accustomed to, he 
must not be permitted a feather or a flock mattress. 
The woven-wire spring mattress, over which a thin, 
soft hair mattress is placed, furnishes the best sick- 
bed; several folds of blankets may be placed over 
this, and between them and the sheet a rubber cloth 
to protect the blankets and mattress from infection. 
The bed-covering should be light, though efficient. 

Great care is of course demanded to prevent bed- 
sores. The sheets should be changed daily, or oftener 
if soiled, and kept smooth beneath the patient, who 
must not be permitted to lie constantly in one posi- 
tion, that continuous pressure on dependent parts 
may be avoided. In some cases an air-, or preferably 
a water-bed may be required, especially in the later 
stages of the disease when the formation of bed-sores 
may seem imminent from the severity and protracted- 
ness of the case. As additional measures to prevent 
these, the back, sacrum, nates, and heels should also 
then be bathed in alcohol in which alum is dissolved, 
or with whiskey, or with spirits of camphor. 

The smallest bed-sore appearing must be kept thor- 
oughly cleansed with a weak solution of an antiseptic, 
such as carbolic acid, salicylic acid, potash permangan- 
ate, and then, as advised by Strumpell, maybe dressed 
with some such preparation as an ointment containing 
one part of balsam of Peru to thirty of glycerite of 



*5 

starch. Equal parts of boracic acid and iodoform 
ointment, is also a good salve. Robinson recom- 
mends one drachm of ichthyol in one ounce of flexi- 
ble collodion. Some prefer a dry dressing, such as 
iodoform or iodol, in combination with finely pulver- 
ized zinc oxide. 

When practicable, it is often desirable to have a 
second bed in an adjacent room to which the patient 
may be carried for the night. This is especially 
gratifying to him, should there be a tendency to 
marked insomnia or restlessness. 

To obviate stomatitis, and especially parotitis 
and middle-ear inflammation, the patient's mouth 
must be frequently cleansed with some antiseptic 
solution, such as a very dilute permanganate-of-potash 
wash. In the later stages of the disease it may be 
necessary that a similar solution be employed, fol- 
lowed by a wash of boro-glycerid. 

Complete rest in bed is imperative from the first 
day that the disease is suspected. By it, with con- 
trol of our patient, we are reasonably certain of a 
favorable issue of the case. The patient under no 
circumstances should be permitted to make ,a long 
journey to reach his home, should the disease develop 
while he is away from it. There is no doubt that 
those cases do the best in every way and have fewer 
complications, with best chances of recovery, that 
have absolute rest, with careful nursing, from the 
earliest period of the disease. When the so-called 



— i6 — 

ambulatory cases, such as are so often encountered in 
hospitals, come under observation at the end of the 
first week or during the middle period of the disease, 
parenchymatous changes have occurred in the heart 
and other tissues as a result of the typhoidal tox- 
aemia,//*^ the fever and over-exertion, leading to a 
fatal issue, which might have been averted by abso- 
lute rest from the beginning of the attack. 

From the first the use of the urinal and bed pan 
must be insisted upon, however mild the case may 
seem. Inability to at first empty the bladder or open 
the bowels in this way, if present, is usually early 
overcome, and it is better to let the patient suffer the 
little inconvenience the novelty of this method may 
have for him at first, when his condition is favorable, 
than to run the risk of inability to habituate him sub- 
sequently when the occurrence of perforation or intes- 
tinal haemorrhage renders the sitting posture out of 
the question. 

Diet in Typhoid Fever. — Both because of the 
natural tendency in all acute febrile diseases to a dis- 
turbance of the digestive functions, with diminution 
in gastric secretory activity, and because in typhoid 
fever, especially, of the marked intestinal disturbance 
existent, it is of the highest importance that the ali- 
ment be of the most digestible sort, and that little or 
no residue be left to form faeces or act as an irritant to 
the ulcerated surface of the intestine. All authorities 
agree in considering milk in some form the best food 



— i7 — 

in typhoid fever. There is certainly none other that 
is so universally used, and about which so little judg- 
ment is exercised in its administration. Though milk 
is beyond doubt in itself the most complete of ail 
single foods and, judiciously administered, the most 
practicable of all that can be employed in typhoid fe- 
ver, it is an error to depend on it alone in the dietetic 
management of any case, since, despite the largest 
daily quantity that can be safely administered, prop- 
erly diluted, the amount of albumin it contains is 
insufficient in an acute wasting ailment, such as 
typhoid fever, to prevent or replace the febrile con- 
sumption of the tissue albuminoids. 

As regards the administration of milk, it must be 
borne in mind that though it is fluid outside the 
stomach, within the latter or within the bowel the 
casein must be coagulated before the digestion of the 
milk is possible. In any febrile ailment, but espe- 
cially in typhoid, the use of milk undiluted cannot be 
too severely condemned. So used in this disease, 
the presence of undigested casein in the stools may 
usually be early noted, coincident with aggravation 
of symptoms of intestinal disturbances already ex- 
istent. In typhoid fever, milk (and this presup- 
poses the use of good milk) should always be given 
diluted. Much water is required by the patient, and 
considerable of this may well be administered added 
to the milk used. The diluent should be either plain 
water, lime-water, or an effervescing alkaline water 

2 RRR 



— 18 — 



such as Vichy, Apollinaris, or soda-water. If an 
alkaline water is not used, it is better to add ten 
grains each of sodium bicarbonate and of chloride to 
the water diluting each half- pint of milk. This 
insures the more efficient digestion of the milk. 
From one to two quarts of pure milk, diluted about 
one-half with the vehicles described, should be 
administered in the course of twenty-four hours. 

If milk diluted as described does not seem to 
agree, but causes flatulence and discomfort and aggra- 
vates the diarrhoea, with the presence of masses of 
casein in the stools, it must be discontinued, or may 
be given in the form of whey.* It may be peptonized 
plain or, in the manner I prefer, with gruel. The 
last is a highly nourishing and satisfactory form of 
fluid food in fevers. f Whey may be made more nour- 



*This is prepared by boiling one pint of milk with one 
to two teaspoonfuls of lemon-juice, and subsequently strain- 
ing through muslin. Yeo suggests that the curd be thor- 
oughly broken up after coagulation in order to express all the 
fluid from it. In this way much of the fat and some of the 
finely divided casein will pass into the whey, thereby increas- 
ing its nutritive properties. 

f Directions for the peptonization of milk, milk gruels, 
and the like, usually accompany the packages of pancreatin 
and soda prepared for this purpose now on the market. 
These may also be obtained from any work on digestion. 
See, preferably, that of Roberts on "Diet and Digestion." 
It is well to have a care in peptonizing, that digestion 
does not proceed too far, as this will result in an unpleasant 



— 1 9 — 

ishing by the addition to it of beef broth, expressed 
meat-juice, or, occasionally, the yolk of an egg. If 
the last, the yolk is previously whipped up in a little 
hot water. 

Peptonized milk may also be prepared with gela- 
tin, J which latter assists in the division of the curd 
and is of undoubted value as a nutrient and albumin- 
sparing food in typhoid fever. Preparations with gela- 
tin must be given, however, with caution if there is 
much tendency to intestinal irritation. During con- 
valescence they are of great value in varying the 
monotony of soft diet. ]f buttermilk is craved, it may 
be given. 

In addition to milk, or the preparations of it tak- 
ing the place of milk when it disagrees, meat broths 
are of the greatest utility in typhoid fever. When 
the case is a light one without marked adynamia, 
the ordinary home preparations of strained chicken-, 
mutton-, or beef-broth, or consomme, may be used, 
alternating with milk. Often, however, meat prep- 
arations richer in albumin than the decoctions are 



bitter taste, rendering the milk or milk-gruel unpalatable. 
The gruel must, of course, be strained while hot. The last 
is usually highly acceptable to the patient's palate and 
agrees well. 

% After the milk is peptonized, it is brought to the boil- 
ing-point to insure destruction of the ferment, which other- 
wise would act on the gelatin and prevent it from solidifying. 
The gelatin is added to the milk while it is yet hot. 



demanded. Cold-made infusions may then be used 
after Roberts' process. (See /. c, p. 185.) These 
are high in nutritive value, but as they cannot be 
cooked without solidifying, from the amount of 
albumin they contain, their raw flavor is apparent and 
objectionable to many. This last, how r ever, may be 
disguised by the addition of some ordinary beef-tea 
or a slice of lemon or a little claret. 

Of the various preparations of beef on the mar- 
ket for the sick, the most nutritive, as well as the 
most palatable by far, is that sold under the name of 
Mosquera's beef-jelly, a predigested paste of beef, 
containing, according to the analysis of Ludwig of 
Vienna, over 53 per cent, of soluble albuminoids 
which have been almost entirely converted into pep- 
tones. The digestion of this preparation of so-called 
jelly is done with the juice of the pineapple, which 
is now known to possess extraordinary proteolytic 
powers, readily promoting proteoses and peptones 
from albumin without imparting the disagreeable 
flavor and odor common to meat preparations digested 
with the animal ferments. But 3 per cent, of this 
beef-jelly is insoluble matter, so that it forms a per- 
fect food for cases of typhoid fever when concentrated 
nourishment is necessary. I have used this prepara- 
tion for several years in preference to any other form 
on the market, for it certainly incomparably outranks 
them all in point of nutritive value and agreeableness 
of flavor. I now rarely treat a case of severe typhoid 



2 1 



fever in private or hospital practice without it. A 
small teaspoonful is added to the cup of boiling water 
or to an equal quantity of chicken- or mutton-broth 
or consomme. Boiling a few minutes improves its 
flavor. During convalescence it may be prepared in 
the same way with the addition of the yolk of an egg. 
When the latter is added, it first is beaten up with the 
beef-jelly, then added to the diluent; or the beef-jelly 
may be added in the preparation of ordinary hot 
chocolate or cocoa, which is occasionally admissible 
through the course of the disease, but especially dur- 
ing convalescence. 

It has been commonly recommended that two to 
three pints of milk and one to one-and-one-half pints 
of beef tea, or some equivalent, be given in the twenty- 
four hours, and that is generally supposed to be about 
the quantity of fluid food necessary to properly sus- 
tain the average patient through an attack of typhoid 
fever. The intervals of feeding should be about t\yo 
to three hours, and a trifle longer interval may be 
allowable through the night, should the patient's con- 
dition be good and his sleep sound. If the patient is 
doing well and sleeps soundly at night, he need not 
be disturbed for nourishment for a much longer in- 
terval, nor by day for at least three to four hours 
when a fair proportion of the twenty-four hours' 
nourishment is taken on each occasion. 

The tendency is oftentimes to over-feed in 
typhoid fever. The key to the regulation of the 



diet, as to the amount and sort of food administered, as 
has been insisted upon by Broadbent, is to be found 
in the careful and frequent inspection of the stools. 
The daily inspection of at least one stool by the phy- 
sician is essential, however trustworthy he may believe 
the report of the nurse to be regarding the appear- 
ance of the evacuations. A tendency to undue loose- 
ness of the bowels is sometimes manifested under 
beef tea, so that this, as well as the danger of in- 
digestion from milk, must also be borne in mind, and 
symptoms appearing must be promptly met by either 
a withdrawal or diminution in the quantity, or a 
change in the mode of administration, of the offend- 
ing substance. 

However ardently fruit may be craved, it is not 
generally allowable in typhoid fever. The juice of 
an orange, small quantities of lemonade, and, occa- 
sionally, the pulp of a few white grapes, may, how- 
ever, be permitted if but little diarrhoea exists. 

It cannot be too strongly urged on the physician 
that pure water be allowed the patient in abundant 
quantity from the start. This is of the greatest im- 
portance in the successful management of the case, 
and should be impressed upon the care-taker. The pa- 
tient's senses are often so obtunded that he is incapa- 
ble of realizing his wants in this direction. Water 
should be given freely, though in not too large quan- 
tity at a time. In addition to that which enters into* 
combination with the milk and meat preparations ad- 



— 2 3 — 

ministered, it should be given in an uncombined state, 
plain or aerated, in small quantity and often. 

Alcohol must not be given as a matter of routine 
in the treatment of typhoid fever, as is too often the 
practice of the medical tyro. It is not, as a rule, re- 
quired in the early stage of the disease, and often in 
mild cases not at all throughout the entire course of 
the fever, save perhaps as a light wine or malt liquor 
during a somewhat protracted convalescence. It 
should preferably only be given to meet certain indi- 
cations, the chief of which is the onset of marked 
circulatory weakness, with such evidence of cardiac 
failure as a toneless or absent first sound and a fre- 
quent, weak pulse. But while its use should not be 
routinely resorted to, its employment must not be 
withheld until a state of extreme exhaustion results, 
from which it may be quite impossible to rescue the 
patient even with our most approved aids at hand. 
This condition should always be anticipated, as much 
as can be, by the timely use of spirits. In those cases 
in which signs of circulatory failure are present, there 
is also apt to be considerable elevation of temperature 
and the presence of nervous symptoms, marked dull- 
ness of intellect, tremor, a dry, brown, glazed tongue, 
with sordes — the case indeed being in that hopeless 
state so well known as the typhoidal. In the typhoid 
state it is often surprising to note the amount of 
spirits that may be administered without the alcohol- 
breath being apparent. Here, too, its effect upon the 



— 24 — 

pulse, increasing tension and volume, and lowering 
frequency, and upon the nervous phenomena, lessen- 
ing restlessness, delirium, stupor, and tremor, is often 
most gratifying. Should, on the contrary, these 
symptoms rather be aggravated by its use, in doses 
which are certain to have had effect, the indication is 
that for some reason, perhaps excessive dosage, the 
alcohol is provocative of harm. 

Apart from the general use of alcohol in typhoid 
fever, stimulants are frequently freely required in the 
complications of the disease, such as severe bronchitis, 
pneumonia, or the condition of approaching collapse 
from haemorrhage. Pepper states that in patients be- 
yond forty years of age, even though of previously 
temperate habits, and younger ones who have been 
intemperate, alcohol had better be given in small 
quantity early. 

Whisky is the form of alcohol most frequently 
used. A wholesome brandy is quite out of the 
question save at a cost beyond the reach of any ex- 
cept the very well-to-do, and even at a considerable 
cost one is apt to be deceived by a factitious prepara- 
tion most harmful of administration through the poi- 
sonous alcohols it contains. Champagne, though espe- 
cially serviceable to meet certain indications, such as 
excessive irritability of the stomach, or the sudden ap- 
proach of collapse, is of less utility as a stimulant for 
habitual daily use in typhoid fever. The amount of 
whisky or brandy required depends entirely upon 



— 2 5 — 

the condition to relieve which it is given, varying 
from one ounce in the twenty-four hours to that 
amount even hourly in cases in which the typhoid 
state is profound. It should be administered well 
diluted with plain water, carbonated water, or in milk, 
and if necessary the dose may be frequently repeated. 

Diet during Convalescence \— After the subsidence 
of fever and the approach of convalescence, a more 
liberal diet is allowable — eggs whipped with milk, con- 
taining a little wine, whisky, or brandy; eggs poached 
or lightly boiled; preparations of gelatin, blanc 
mange, and the like; the soft part of oysters, milk 
toast, and milk puddings, are all permissible; but no 
really solid food should be allowed until convalescence 
is well advanced — it must not be permitted while the 
least tendency to diarrhoea exists, nor should it be 
allowed until the temperature has been normal for a 
week. Not infrequently what has seemed but a slight 
indiscretion in diet has apparently been the means of 
precipitating a recrudescence of the fever, and more 
than once perforation, followed by collapse and death, 
has succeeded a too early indulgence of the appetite 
in cases in which typhoid ulcers have not completely 
healed, though the temperature has been normal for 
several days^ 

In all severe cases, as before remarked, the di- 
gestive functions are usually profoundly affected, 
especially the gastric — and probably the pancreatic 
— secretory activity; and these cannot be expected to 



— 26 — 



resume their normal condition immediately with the 
subsidence of the fever. In all cases in which semi- 
solid food, or subsequently the light solid food at first 
given, causes symptoms of indigestion, especially such 
as oppression in the epigastrium, with flatulence soon 
after meals, either the nourishment should be admin- 
istered predigested, or digestants should be liberally 
taken at the time of eating. An active malt extract 
is of the greatest value in these cases, given immedi- 
ately before the meal; and after a meal in which albu- 
minoid food forms a part, either a good preparation of 
papain or pepsin should be used. Of course, if the 
latter is prescribed, it should only be in combination 
with dilute hydrochloric acid, and this in quantity not 
less than half a drachm, to obtain any digestive action. 

Among the countless remedies and many plans 
suggested for the successful management of a case of 
typhoid fever, but two methods of treatment at the 
present day are alone worthy of detailed mention: 
First, the justly celebrated Brand method of baths; 
and, Second, the use of certain antiseptic drugs sup- 
posed to exert a lethal effect upon the germs of the 
disease or an antidoting action upon their toxic prod- 
ucts. All other forms of treatment, excepting the 
antipyretic by drugs (which is considered in the man- 
agements of the complications), may be included in 
what has been long termed the expectant and the 
expectant-symptomatic . The names of these are suffi- 



— 27 — 

ciently self-explanatory and, as plans of treatment 
pure and simple, self-condemnatory, to deserve no 
extended mention in this book. The expectant 
method, and the expectant-symptomatic plan of 
treatment, which can how be said to be obsolete with 
the progressive physician, were once more or less the 
prevailing methods, when little existed to indicate 
that either the duration of the fever or the severity 
of the symptoms could be markedly controlled by 
therapeutic measures. 

By the expectant method, nothing whatever was 
knowingly done on the part of the attendant to influ- 
ence the cause or the duration of the disease, save 
attention to matters of hygiene, such as diet and the 
like. In the expectant-symptomatic, or so-called 
rational plan, no attempt was made to foresee or 
guard against the appearance of ill-omened symptoms 
or to reach their cause. Here effort was alone made, 
as best it could be, to treat these symptoms as they 
arose. But, as Wilson * so understanding^ remarks, 
too often the appearance of grave symptoms indicates 
mischief already past remedy; hence the aim of treat- 



* These various plans are considered in a splendid arti- 
cle by J, C. Wilson on the Treatment of Typhoid Fever with 
special reference to the method of Brand (Medical News, 
Dec. 6, 1890). I am indebted to this paper and others by 
Professor Wilson for many points of value in what follows 
concerning the method of Brand, advocated with such ability 
by this distinguished clinician. 



— 28 — 



ment must not be simply to control serious symptoms 
as they arise, but, by acting upon their cause from 
the beginning, to anticipate their development. It 
would appear that it is within our power to do this in 
all cases of typhoid fever, provided we can have con- 
trol of them from the start, or before the disease has 
gained sufficient headway to baffle our efforts. 

As the method of baths, more especially that of 
Brand, is in effect far-and-away superior to all other 
plans of treatment extant, or to any known remedy 
or combination of drugs, it will receive priority of 
mention, as it should also receive priority of thought 
by every one called upon to treat cases of typhoid 
fever. 

Through an utter lack of conception of the im- 
mense influence for good which the Brand method of 
baths, applied from the earliest period in the fever, 
has been shown to exert — not alone on the febrile con- 
dition itself, but also on the multiplicity of symptoms 
originated by the toxic process — the method is usually 
narrowly classed with antipyretics as a remedy for 
reduction of fever heat alone. This is especially 
common practice with English and American clin- 
icians writing on the treatment of typhoid fever, 
with the noteworthy exception in this country of J. C. 
Wilson and Simon Baruch, to both of whom so much 
credit is due for that continued warm advocacy of the 
method which has done so much in this country to 
popularize and introduce it, not alone in our hospitals, 



— 2 9 — 

but in private practice as well. It cannot here be too 
strongly insisted that the treatment by the Brand 
method of baths, when early and intelligently applied, 
exerts in the majority of cases of typhoid fever an 
effect so extraordinary that were such obtained by the 
use of any single antipyretic drug, supposedly acting 
by virtue of an antidotal power over the typhoid germ 
or its toxines, it would be lauded as a specific, and 
further search for a remedy would in all probability 
be abandoned. For indeed the effects of the Brand 
method, when resorted to early, are little short of 
specific, and have, somewhat for this reason, been 
likened by Baruch to the action of quinine in the 
early treatment of the severer forms of malarial 
fevers. Regarding this, Baruch remarks: u Any one 
who has, like myself, treated a large number of cases 
of the severe types of bilious, remittent and conges- 
tive fevers on the Southern river-banks, has realized 
how important it is to cinchonize the patient at the 
earliest possible moment in order to prevent the re- 
currence of the paroxysm, which brings parenchyma- 
tous changes in its train. When the latter are once 
established, the fever continues despite the best 
directed administration of quinine. The antagonistic 
specific effect of quinine is no longer required; we 
have a hepatitis, a gastritis, or splenic enlargement to 
treat, with which we are unable to cope successfully. 
But if the malarial element be not wisely met by qui- 
nine, the patient will surely die from the combination 



of the malarial and the parenchymatous diseases. So 
it is with typhoid fever. The cold bath represents 
the effect of quinine in malarial fevers; although it 
has not the specific antidotal effect, the cold bath ap- 
plied in the early stage has the same prophylactic 
effect in preventing parenchymatous degenerations." 

Prior to the introduction of systematic cold baths, 
after the method of Brand, in the treatment of typhoid 
fever, statistics everywhere showed under all modes 
of treatment a. mortality of startling height in com- 
parison to that now exhibited under the use of the 
Brand method, even when modified or carried out 
with details unlike those insisted upon by Brand. 
Thus, of 11,124 cases in Germany under the so-called 
expectant treatment, the mortality amounted to 
somewhat over 21 per cent; in upward of 14,000 
cases under treatment in the various London hospi- 
tals, the mortality averaged some 17.8 per cent. 
Murchison collected some 27,000 cases, with an aver- 
age mortality of 17.45 per pent. Of cases treated in 
Europe, Jaccoud collected 80,140 cases, with a mor- 
tality of 19.23 per cent. In the New York Hospital, 
over a series of some six years, during which 1,305 cases 
were studied, the mortality estimated by years varied 
between a minimum of 20.1 per cent, in 1879 and a 
maximum of 30 per cent, in 1890.* These figures 

* Delafield, quoted by Wilson. I am indebted to Dr. 
•Baruch's most excellent manual on The Uses of Water in 
Modern Medicine, for many of the statistics here given. 



— 3i — 

show that the mortality of typhoid fever everywhere 
under the most favorable auspices, excepting baths, 
runs between 15 and 25 per cent. In private prac- 
tice, for various reasons, much less mortality prevails, 
10 per cent, being recorded by most observers as a 
fair average. 

The fact, however, must not be lost sight of, that 
unless a very large series of cases are selected in com- 
puting results, deductions drawn from methods of 
treatment are little to be depended upon. Thus, 
Professor Pepper once treated a series of 100 consecu- 
tive cases of typhoid fever in private practice with 
nitrate of silver. As in these the mortality was nil, 
it might be concluded that we have in nitrate of sil- 
ver a remedy approaching the specific in its effects in 
the treatment of this disease; and yet, so far as I am 
aware, this remedy, though quite generally used 
(largely because of Pepper's warm and continued ad- 
vocacy), has been found of no especial value by others, 
no better results being obtained with it than under 
the expectant plan of treatment. In localities in which 
typhoid fever is endemic, such as Philadelphia, and in 
localities in which it occurs as an epidemic, it some- 
times happens that the majority of cases are especially 
mild, as is often the case with other of the acute in- 
fectious diseases; in the treatment of these mild cases, 
especially when occurring among the well-to-do in pri- 
vate practice, markedly good results are often ob- 
tained in series of cases by the use of some drug or 



— 32 — 

treatment dictated by the fancy of the attendant, which 
results are undoubtedly of the post hoc and not of 
the propter hoc order. The cases being mild in char- 
acter and taking early to their bed, good nursing 
alone would have been efficient to bring about re- 
covery. It is otherwise when statistics are gath- 
ered from extensive series of cases occurring in dif- 
ferent localities over long periods, as is now the 
case with those furnished by the adherents of the 
Brand treatment of typhoid fever. Thus, Brand's 
carefully collected statistics of 19,017 cases show that 
under all kinds of cold-water treatment, in which in 
many cases no strict enforcement was observed, the 
mortality sank from 21.8 to 7.8 per cent. In 2,198 
other cases collected by Brand from various sources 
in which his method was carefully carried out, the 
mortality was 1.7 per cent.; and in 1,223 cases in pri- 
vate life, civil and military hospitals, treated by Jur- 
gensen, Vogel, and Brand, there was a mortality of 
only one per cent., of which deaths (twelve) not one 
occurred in any case coming under observation before 
the fifth day of the disease. 

Though the excellence of Brand's results was 
apparent soon after his first publication on the sub- 
ject in 1861, and in marked contrast to the results 
obtained by other methods of treatment, many years 
elapsed before the recognition was accorded them 
that was their due, even in Germany; and though in 
France, through Glenard of Lyons — who, as a prisoner 



— 33 — 

of war in Stettin, in 1873, witnessed the extraordinary 
successes of Brand, — the method has become very 
popular, with results similar to those of Brand, scant 
headway has been obtained for it in this country or 
in England.* 

In this country it has been taken up especially 
by Baruch, Wilson, Sihler, Thompson, Peabody, 
Smythe, and Borning, all of whom have reported 
series of cases with results confirmatory of those of 
Brand. 

There seems no doubt that for the most benefit 
to occur from the method, the earlier in the case the 
treatment is begun the better. So convinced was 
Brand especially of this that he positively asserted 
not only that all cases coming under treatment before 
the fifth day of the disease ran a milder course, but 
that all such should recover. The experience of all 
other observers in all military hospitals in which the 
cases come under observation early, support this view, 
as does the fact of the invariable higher mortality of 

*The case is different in one of the colonies. Hare, of 
Australia {Practitioner, March, 1891), reported a large series 
of cases treated by the bath, but with the coincident use of 
antifebrin and quinine. His mortality in 1,173 cases was 
7.84 per cent., about the same as that obtained by Vogel in 
his hospital under the same mixed treatment. Apparently 
a much less mortality might have been expected under the 
strict cold-bath treatment. Still, this percentage of deaths, 
compared with that of 14.82 in 1,828 cases previously treated 
by the expectant method, is very significant. 

3 RRR 



— 34 — 

cases treated later reported by these and other ob- 
servers. 

It would appear that the very early use of the 
Brand method, before marked systemic infection has 
occurred, will in the majority of instances, when faith- 
fully carried out, prevent the latter. It has even been 
asserted that little or no intestinal ulceration ensues, 
the alteration in Peyer's patches not going beyond 
the stage of infiltration. This seems not improbable, 
in view of the favorable course the majority of cases 
pursue when they are brought under this treatment 
in the early stage of the disease; in these, the diminu- 
tion in intestinal symptoms, cessation of excessive 
diarrhoea, early cleaning of the tongue, and the ap- 
pearance of appetite, demonstrate the remarkable 
effect that this treatment must have on the infection. 
The experiments of Roque and Weil,* which were 
made for the purpose of studying the elimination of 
toxines in typhoid fever, show that in patients treated 
by the cold-bath method the uro-toxic coefficient! 
becomes greatly increased, attaining an amount equal 
to five or six times the normal. This increase lessens 
with decline in temperature and general improvement 
in symptoms, and falls to normal coincidently with 
disappearance of fever. While under no treatment 
the uro-toxic coefficient is only about double that of 

* Rev. de MM., December, i8qr. 

f '* The quantity of toxic matter which a unit of weight 
produces in a unit of time." Bouchard: "Auto-Intoxication 
in Disease." 



— 35 — 

health, and continues above normal for four or five 
weeks after abatement of fever, under antipyrin dur- 
ing the fever it falls below the normal, to become 
enormously increased during convalescence. This 
shows a decidedly harmful action on the part of anti- 
pyrin in promoting retention of toxines, which effect 
is also produced by other of the coal-tar antipyretics. 
This also indicates the special value of the cold-bath 
treatment in promotng elimination of the toxic prod- 
ucts of the disease. 

The technique of the^method of Brand is so well 
given by Wilson in his paper before referred to that 
I here excerpt the following describing it: 

" Whenever the temperature taken in the rectum 
reaches 102. 2 0 F. (39 0 C.) the patient is placed in a 
bath of 65 0 F. A compress, wet with water about 
five degrees lower, is placed upon the head, or water 
at a lower temperature is poured upon the head and 
shoulders. The patient remains in the bath fifteen 
minutes, during which time he is systematically rubbed 
by the attendants and encouraged to rub himself. At 
the expiration of that time he is removed from the 
bath, and wrapped in a coarse linen sheet over which 
a blanket is folded, the extremities being thoroughly 
dried and rubbed. A little wine or spirits is then 
given. This is repeated every three hours, unless the 
temperature remains below 102. 2 0 F. The alimenta- 
tion is liquid, nutritious, and carefully regulated. No 
drugs are administered. 



- 36 - 

"Glenard* gives the following outline of the 
technique of the treatment by cold baths: 

"'If the diagnosis of typhoid fever is probable, 
recourse should be had to the baths, whatever may be 
the symptoms. The full tub should be placed in the 
ward or chamber, parallel to the bed at a distance of 
one or two metres, the floors properly protected by 
oilcloth, and a screen placed between the bed and the 
bath-tub. A sufficient quantity of water should be 
used to cover the patient's body to the neck. It 
should be of a temperature of from 64.4 0 to 68° F. 
(18 0 to 20 0 C). The baths should be prepared with- 
out disturbance or noise. There should be placed on 
the floor near the head of the tub two pitchers of cold 
water of a temperature of from 46. 4 0 to 50 0 F. (8° to 
io° C), each containing four or five quarts (litres). 
A glass of water should be at hand. The first bath 
should be given preferably about four o'clock in the 
afternoon, unless there is some urgent reason for 
selecting a different hour; and the physician should be 
present. The rectal temperature is taken, the urine 
is voided, and the patient is assisted into the full tub, 
the screen having been removed. If there is perspira- 
tion, the patient is dried before entering the bath. 
Cold water from the pitchers is poured upon the 
head and the back of the neck, for one or two min- 
utes, the amount being from two to three quarts 



* Le Bulletin Mttdicale, Feb. 26, 188S. 



— 37 — 

(litres). Then a swallow of cold water or red wine is 
given. This being done, the whole surface of the 
body is briskly rubbed with a sponge or brush, and 
the patient is made to rub his abdomen and chest. f 
These frictions stimulate the peripheral circulation, 
prevent the accumulation of heat at any one point, 
moderate the sensation of cold, and help to pass the 
time; they are not indispensable. Shivering appears, 
as a general rule, in between eight and twelve minutes; 
this is a necessary evil to which too much attention is 
not to be paid. Toward the middle of the bath, or at 
its termination, cold water is again poured over the 
head and neck. The time occupied ought to be at 
least fifteen minutes— longer if the head is still warm 
and the cheeks red, or if the temperature of the pa- 
tient was very high before the bath. 

" * The patient should leave the bath without pre- 
cipitation. He cannot take cold — thoracic complica- 
tions are caused by typhoid fever and not by chilling. 
The air of the apartment should be pure and not too 
warm; the window should be opened in the intervals 
between the baths — during the bath it ought to be 
closed. On leaving the bath, the patient should be 
gently dried with a towel. The bed should be Garc- 
ia f Too much attention cannot be paid to the application 
of thorough friction. The physician, or a trained substitute, 
should always be on hand to superintend the baths, at least 
until the attendants are themselves thoroughly versed in the 
technique. — D. D. S.] 



- 3« - 

fully made during each bath. If on returning to the 
bed shivering takes place, the limbs should be rubbed 
and a hot bottle placed at the patient's feet. A cold 
compress, covered with oil-silk or flannel, should be 
placed over the abdomen, and a little warm nourish- 
ment administered. 

" 6 Three-quarters of an hour after the bath the 
rectal temperature should again be taken. If, how- 
ever, it is found to be below ioi° F. (38. 5 0 C), it is 
not necessary to take it again for three hours. 

" i Neither age, sex, menstruation, pregnancy, nor 
sweating (except that which occurs at the end of de- 
fervescence) in any way modifies the treatment. In 
women who are weaning their children, cold com- 
presses should be applied to the breasts and fre- 
quently renewed. If diarrhoea persists, it is to be 
combated by cold compresses, which may be kept cold 
by the aid of a bladder of ice. If there is constipa- 
tion, it is to be treated by cold enemata, and, if these 
fail, by enemata consisting of one part of cold water 
and one part of fresh ox-gall. 

" \ When the temperature before the bath is very 
high, or if the fall forty-five minutes after the bath is 
less than i.8° F. (i° C.)., the bath must be prolonged 
to eighteen or twenty minutes. It is very rarely 
necessary to modify the general formula. After the 
temperature does not exceed 102. 2 0 F. (39 0 C), but 
yet reaches iot° F. (38. 5 0 C), it is necessary to treat 



— 39 — 

these slight exacerbations by baths of 68° F. (20 0 C.) 
and of five minutes' duration in order to prevent the 
prolongation of the fever or the occurrence of relapse, 
and to shorten convalescence. If relapse occurs, it 
must be treated according to the general formula. 
When the temperature no longer exceeds 101 0 F. 
(38. 5 0 C), defervescence being established, the baths 
are discontinued, and the patient should be treated as 
convalescent, but is to be kept in bed until the tem- 
perature has not exceeded 100.4 0 F. (38 0 C). for four 
days. He may then rise, and in a short time walk in 
the open air; he may prolong his promenades accord- 
ing to his strength, and one will be struck by the 
rapidity with which his strength increases after every 
outing. Proper precautions are to be taken against 
cold. 

" i During the treatment by baths, one attendant 
is required for the day and one for the night; these 
duties may be fulfilled by members of the family. In 
a hospital one bath-tub may be used for a dozen pa- 
tients, but it is better to use one for every six patients. 
Two attendants are sufficieut for twelve patients. It 
is not necessary to renew the water of the bath every 
three hours; once in twenty-four hours is sufficient. 
The patient treated from the beginning in this man- 
ner, never suffers from faecal incontinence. As a 
rule, the patient should pass his water before enter- 
ing the bath. During epidemics, the water of the 
bath, if it is not soiled, should serve for several 



— 40 — 

patients, and should only be renewed two or three 
times a day.' 

" This," states Dr. Wilson, "is the line of treat- 
ment to which, rigorously carried out, the extraordi- 
nary results which I have indicated are ascribed. 
That it seems heroic, thus briefly stated, cannot be 
denied. That it is heroic to those who see it prac- 
ticed for the first time, is more than true. Precon- 
ceived notions in regard to the management of ty- 
phoid cases are violated. The frequent disturbance 
for the purpose of taking temperatures and bathing, 
the fact that the patients are compelled to rise from 
their bed and with the aid of the attendants to step 
into the bath, the pallor, shivering, and the blueness 
of the extremities which shows itself during the course 
of the bath and continues for a varying time after the 
patient is put to bed, demand conviction on the part 
of the physician, and the courage of conviction to 
continue. 

" It is only when the favorable effect upon the 
condition of the patient is seen, and when we reflect 
that in every hundred cases at least ten lives which 
would be lost under the expectant-symptomatic treat- 
ment are saved by strict cold bathing, that we dare to 
proceed. 

" What is the effect upon the course of the dis- 
ease in cases treated from the beginning — that is, be- 
fore the fifth day ? Brand declares that the classical 
picture of typhoid fever is no longer seen. It may 



— 41 — 

be objected to this that we do not get our cases 
before the fifth day, and even if they come under ob- 
servation so early a positive diagnosis cannot always 
be made at that time. Only in garrison life and in 
epidemics will a treatment so radical be justifiable at 
the onset of a vague febrile disease. But Brand's 
statement is true of cases in which treatment is insti- 
tuted at a later period, even so late as the middle of 
the second week. After six or eight baths the famil- 
iar picture is no longer seen. Delirium ceases; stu- 
por gives way to light somnolence from which the 
patient is easily aroused with a bright expression and 
a clear mind. The tongue becomes moist and clean, 
and remains so. There is desire for food, and very 
commonly a complaint of hunger. The abdomen is 
not tympanitic. Diarrhoea is rarely excessive or 
troublesome. In short, there remains, in the words 
of Brand, of the ordinary picture of typhoid nothing 
more than (a) a moderate fever, (b) an unimportant 
bronchial catarrh, (c) enlargement of the spleen, (d) 
the rose rash, and (e) infiltration of the intestinal 
glands. Everything else is prevented, and what 
might have been a severe case runs its course as a 
mild one if the patient is brought under treatment 
sufficiently early. Exceptions to this statement occur 
only when complications develop at the onset. There 
are rapid wasting and progressive anaemia, as in all 
prolonged febrile diseases, but severe enteric fever is 
changed to mild, the mild to a still milder form. 



— 42 — 

This is brought about through the control of the tem- 
perature and by preventing disturbances of normal 
functions. The treatment is directed against the 
typhoid process as an entirety. 

"It does, it is true, not only reduce the tempera- 
ture; the repetition of the bath also cotttrols the tem- 
perature and keeps it down. But the bath does much 
more than this. It acts upon the nervous system in 
such a manner as to enable it to withstand the toxic 
influences of the infecting principle and the products 
of its evolution. This it doubtless does by the action 
of cold water upon the peripheral nerve-endings, a 
reflex stimulus being transmitted to the nerve-centres 
presiding over the circulation, respiration, digestion, 
excretion, and nutrition. This general reinforcement 
of function is shown by improved action of the heart, 
the first sound continuing distinct, the pulse being 
slower and more regular, and the improvement in the 
arterial tension showing itself by an absence of 
dicrotism; by persistence of appetite and digestive 
power, permitting freer alimenation without gastric 
disturbances; by deepening and slowing of the respi- 
ration; and by the absence of nervous symptoms, the 
increased excretion, the prevention of complications, 
and the rapid convalescence. 

"As was pointed out by Jiirgensen, every attempt 
to deviate from the routine treatment as above laid 
down is followed by less satisfactory results. The 
treatment thus stands by itself as a definite procedure, 



— 43 — 

to be distinguished from treatment by graduated 
baths, the cold pack, cold affusions, spraying, and 
other hydro-therapeutic measures. It is especially to 
be looked upon as something distinct and different 
from the antipyretic treatment. Upon this Brand 
and his followers insist. " 

The following paragraph is from Baruch's most 
excellent book: 

" The question has been asked: Is the rule to 
bathe every three hours in winter, at 65 ° F., whenever 
the temperature reaches 103 0 F., absolute, and not to 
be modified to adapt it to each case? Most assuredly 
I would rarely deviate from the rule except in the 
beginning, when patients' peculiarities may be noted; 
because this rule has been established by deductions 
from large clinical material, carefully gathered by 
numerous observers in different localities, in private, 
hospital, and military practice. It must always be 
borne in mind, too, that the object of the bath is 
prophylactic; its aim is not a mere reduction of tem- 
perature, but a suppression of the violence of the 
febrile movement until it has spent its force. Who- 
ever expects to throttle the fever by the bath will 
surely be disappointed, for its course is as steady and 
inexorable as any law of nature. The temperature 
will almost invariably fall from one to three degrees 
after each bath, only, however, to rise again to within 
a fraction of its former rate when three-hourly ex- 
amination is made. But from day to day there will 



be a gradual yet steady diminution of the average 
temperature, which indicates that the resisting power 
of the system is gaining sway over the disease. This 
is the usual effect of the systematic cold bath, admin- 
istered without fear and without favor. Whenever 
we attempt to substitute another form of hydriatic 
procedure, to raise the temperature of the bath water, 
to shorten the duration of the bath, or otherwise to 
change the rule, we must expect a change in the re- 
sult. If the case comes under treatment late, the re- 
sisting power of the disease will be greater, hence the 
result of the bath will deviate from that here depicted. 
The type of the severity of the disease, too, will exert 
its influence upon the latter. If the temperature fails 
to be favorably influenced by the systematic baths at 
65 0 F., a lower temperature for a more brief period, 
not below 6o° F., will be found useful in the first two 
weeks of the disease." 

It must not, however, be supposed that Brand's 
rule regarding the temperature of the bath water is 
inflexible for all cases. In a recent letter to Dr. 
Baruch, Brand states that in cases in which the patient 
has been ill for over four days, and in certain others 
in which the patient is bathed from the start, he al- 
ways resorts to water of a higher temperature, usually 
that of the room, for the first twenty-four hours. 
This is in accordance with Bouveret, who, in 100 cases 
treated strictly by the cold bath, had a mortality of 
but 3 per cent., the average date of admission of the 



— 45 — 

fatal cases being the sixteenth day. In the treatment of 
these, Bouveret used initial baths at a temperature of 
8o° F., reducing the temperature of the bath to 65 0 F. 
if the fever did not yield readily. 

Baruch points out that in cases coming under 
observation late, the condition of the heart is the 
chief index to the temperature of the bath to resort 
to. He states that reaction from a bath of 65° F. re- 
quires a certain integrity not only of the central nerv- 
ous system, but also of the heart muscle. Should 
the febrile process have been long continued, degen- 
eration of the cardiac muscle is not unlikely. In such 
a case the bath technique must be modified to meet 
the indications; at first, only the graduated bath of 
Ziemssen or the wet pack may be used, or a warm 
bath with cold affusions followed by friction; subse- 
quently, should considerable improvement in physical 
tone occur, the regulation Brand method may be ap- 
plied. 

The importance of insuring a good reaction from 
the bath cannot be too strongly urged. In propor- 
tion as the patient reacts badly, and shivering and 
blueness of the extremities occur and continue, is the 
object for which the baths are given defeated. There- 
fore, friction of all parts of the body, save the abdo- 
men, is absolutely essential. It is often desirable, and 
indeed necessary, to administer a stimulant after the 
bath. This, preferably whisky, should be given in 
hot water. It is my practice in many cases to give a 



- 4 6 - 

half-ounce of whiskey immediately before the bath 
and a cup of hot meat-broth immediately after. 
When reaction is poor, despite friction during the 
bath and stimulants immediately before or after, hot 
bottles should be applied to the extremities within the 
blanket. Nitro-glycerin may also be liberally used, 
either with the hot toddy or beef broth. 

There certainly seems no doubt that no such re- 
sults are obtained by means of the pack or the 
graduated bath of Ziemssen as with the method of 
Brand rigidly enforced.* 

Treatment by prolonged warm baths has been 
recommended by Reiss, of Berlin, and practiced by 
himself and others as a substitute for the Brand 
method, as a means of slowly though permanently 
extracting heat. In this, the patient is immersed in a 
bath of 88° F., suspended from a hammock. The 
patient remains in the bath by day and, if necessary, 
by night until the rectal temperature reaches ioo° F. 
On a recurrence of the former temperature, prolonged 
immersion is again practiced in the same manner. 
Reiss reports very good results; his mortality (8.5 per 
cent.) is lower than that by the graduated-bath method, 
in a series of 809 cases. 

*With the Ziemssen bath the water temperature is at 
first 90 0 F. ; subsequently it is reduced to 72 0 F. for a half- 
hour. Ziemssen especially recommends these baths for use 
in private practice. The mortality of 2,000 cases treated by 
the graduated bath of Ziemssen was 9.6 per cent. — far higher 
than that by the strict Brand method. 



— 47 — 

This method, however, is not comparable to that 
of Brand when the application of the latter is at all 
feasible. The last is certainly gaining headway in 
this country, not only in hospitals, bat in private 
practice, under such strong advocates as Wilson and 
Baruch. At least one obstacle to its general adop- 
tion, apart from the prejudice and opposition to the 
method to be overcome on the part of the laity, is 
the difficulty of procuring at short notice suitable 
bathing arrangements. Portable tubs to meet the 
emergency have recently been suggested. 

Regarding contra-indications to the use of the 
Brand method, the small mortality attending the cases 
in which the baths are used, the early appearance of 
benefit from them, with lessening of all complications, 
indicate that few if any disadvantages appertain to 
them. It has been said, but on no evidence, that the 
tendency to intestinal haemorrhage is increased. The 
statistics of Brand and others show conclusively that 
the reverse is the case. The patient, of course, must 
not be subjected to the bath if peritonitis of perfora- 
tion has occurred, or if he should be in a state of col- 
lapse from any cause whatsoever. 

The diminished utility of baths in cases coming 
under observation at the middle or late stage of the 
disease has already been spoken of, but even in cer- 
tain of these the benefit from the Brand treatment is 
most striking. Should the condition of the cardiac 
muscle warrant the use of the plunge, indicating some 



— 4 8 - 

ability to react, however late the case be seen, the 
baths 'should be administered. If the reaction is 

to 

poor, or the plunge be not used for fear of the latter, 
it would be well, as Brand advises, to rather resort to 
the wet pack or to a warm bath with cold affusions 
followed by friction. This, Baruch remarks, may re- 
store the lost stamina, and, later, enable us to resort 
to the cold bath if symptoms demand it. 



SPECIFIC AND ANTISEPTIC TREATMENT OF 
TYPHOID FEVER. 

Although typhoid fever is in all probability due 
to one or more micro-organisms, the products of the 
life's growth of which originate the assemblage of 
symptoms constituting the disease, little has yet been 
done, though much has been proposed and tried, 
toward destroying the materies morbi in the body, or 
directly antidoting the typhoidal toxines, by the 
administration of drugs. It must be said that as yet, 
unfortunately, no actual specific or antidote has been 
discovered. Were typhoid fever, as is cholera, for a 
time a local disease, its early symptoms due to the 
irritant action of bacilli in portions of the body not 
beyond the reach of the application of specific rem- 
edies, much might be hoped for from the use of cer- 
tain insoluble intestinal antiseptics, such as the naph- 
thols or their salts, the former of which are of such 
utility as germicidal agents. But unfortunately, 
though like cholera the complexus of symptoms is 
chiefly if not altogether due to the toxines originated 
by the micro-organisms, unlike cholera the typhoidal 
germs, besides having a nidus in thp lymphoid ele- 
ments of the bowel, early enter the interior of the 
body, through the alimentary canal, gaining entrance 
to and multiplying in the mesenteric glands, the 
spleen, and the liver. They thus become wholly inac- 
cessible to insoluble antiseptics. 

4 RRR 



— 5° — 

Toward neither the germs themselves, when sys- 
temic infection by them has occurred, nor their speci- 
fic poison, has any antiseptic drug thus far proposed 
been found to exert so distinctly antidotal an influence 
as to be depended upon in any given case to surely ren- 
der the course of typhoid fever mild or to abort the 
disease. It is, however, a fact that must be admitted, 
and indeed is by many careful clinicians, that in the 
treatment of typhoid fever by certain of the antisep- 
tics, to be hereafter mentioned, results invariably bet- 
ter have been obtained than those by either the expect- 
ant or the expectant-symptomatic method alone. A 
few of these antiseptics offer such promising results, 
largely through their power of destroying the toxic 
alkaloids and the germs producing them, that one or 
more of them would be well worth trial as a routine 
treatment in typhoid fever, did we not have in the 
early application of the Brand method a plan of 
treatment which, it would appear, may be depended 
upon to furnish better results in all cases than any 
other. 

Although it is impossible to investigate the Brand 
method without being satisfied as to its great superi- 
ority, unfortunately, at the present time, it is difficult 
of application in private practice, both because of 
lack of convenience and attendants for its successful 
operation, and on account of the prejudices of those 
near the patient, who cannot but look upon the cold 
bath in cases of illness as barbarous in the extreme, 



if not actually homicidal. Were conveniences at 
hand, and attendants upon whom one could depend, 
a few days' application of the method would probably 
convince the most skeptical of its harmlessness and 
beneficence. But with trained attendants lacking, 
even did the ingenuity of the physician overcome the 
difficulty of lack of portable bathing contrivances, it 
would require not only great resolution on his part to 
master the family prejudices, but willingness and 
ability to sacrifice much time and comfort in constant 
personal attendance on the patient, in order that the 
method might be pursued with that eye to the mi- 
nutiae so necessary for success. For these and other 
reasons, too apparent to be dwelt upon, its applica- 
bility in private work is often practically out of the 
question, and one must have recourse to other modes 
of treatment. Of these the most promising is the use 
of antiseptics which are supposed to have some power 
over the infective principle of the disease, either as it 
occurs in the bowel or in the stomach. Among the 
remedies supposed to be of some utility in this direc- 
tion may be especially mentioned the naphthols; 
naphthalin; thymol; a mixture of carbolic acid and 
tincture of iodine; quinine; sulphurous acid; chlorine- 
water; and calomel. 

Of the various remedies suggested for their anti- 
septic effect, I have long especially favored the use of 
naphthol-/?. This drug, which I first began to use 
many years ago under the guise of " hydro-naphthol " 



— a proprietary preparation which I have recently* 
shown is identical with ordinary impure naphthoh/? — 
possesses many advantages over other antiseptics pro- 
posed for their local intestinal action in typhoid fever. 

There is no doubt that — from the gastro-intestinal 
catarrh present in typhoid fever of microbic origin, 
largely due to specific infection of the bowel by the 
typhoid bacillus, with secondary absorption of poi- 
sonous toxines there generated— a microbicide, to 
be of service, should be a more or less ideal intes- 
tinal antiseptic. As I have elsewhere f expressed 
it, in suggesting a remedy for cholera, it should be 
one but slightly soluble and decomposable, yet a ger- 
micide in aqueous solution, and both non-toxic and 
non-irritant in doses sufficient to exert a germicidal 
action. 

In the first place, purified preparations of naph- 
thol are absolutely *non-toxic in any dose possible 
to be ingested, as has been conclusively shown by 
Bouchardat and others, J and it is likewise unirritating 
in doses sufficient to exert and maintain an antiseptic 
effect in the bowel. Naphthol has been shown to 
be especially inimical to the typhoid germ, and has, 
moreover, as Teissier of Lyons has shown, a marked 
effect in preventing the production of the toxines of 

* Medical News, April I, 18Q3. 
\ Medical News, Oct. I, 1892. 

\ See my paper on 11 Treatment of Cholera by the Naph- 
thols," American Journal of the Medical Sciences, April, 1893. 



— 53 — 

the disease, both during the fever and in convales- 
cence. From its utility in my hands in cases of sim- 
ple diarrhoea, dysentery, and other ailments depend- 
ent upon microbial infection, I began its use several 
years ago in the treatment of typhoid fever in both 
hospital and private practice, and still employ it, 
either alone or in combination, in certain cases in which 
the cold-bath treatment is used, believing that my re- 
sults with it are better than are obtained by other 
antiseptics proposed; and in this I have recently 
been supported by Bouchard, Petresco of Bucharest, 
Clarke of Bristol, Tiessier of Lyons, Moncorvo of 
Rio Janiero, Maximovitch, Mason of Boston, and 
others. 

My usual mode of administration of naphthol is 
to give it very finely pulverized in the form of powder, 
wafer, capsule, or emulsion, with a suitable excipient, 
in doses of five to ten grains, three to five times daily. 
Bouchard, who has had excellent results with beta- 
naphthol in typhoid fever, administers it in daily 
doses of one to four grammes, in combination with an 
equal quantity of bismuth salicylate. 

Petresco reports that he has had more favorable 
results with naphthol than with any other remedy; he 
gives it in doses of a gramme three times daily, and 
believes that under this dose the course of the disease 
is favorably modified. 

Clarke, of Bristol, who, like Mason of Boston, is 
unaware of the identity of the so-called " hydro- 



— 54 — 

naphthol" and beta-naphthol, reports* also very 
favorably on the use of the latter and its proprietary 
double in typhoid fever. As a result of the use of 
naphthol in a number of cases, he reported a reduc- 
tion in the average duration of the fever, modification 
of the offensive smell of the passages, more or less 
relief of abdominal tenderness* and meteorism, with 
early clearing of the tongue, and less dryness of 
mouth and lips; convalescence, also, seemed more 
rapid, and tendency to secondary complications was 
diminished. 

Mason f reports a series of 675 cases treated with 
hydronaphthol (impure beta-naphthol). His results 
were excellent. 

Tiessier and Maximovitch prefer alpha-naphthol 
to its isomer beta-naphthol. The former gives it in 
six-grain doses, combined with bismuth salicylate, and 
also promotes free diuresis by the use of cold-water 
enemas ; he found that as soon as intestinal anti- 
sepsis has become established by this means, the 
urine becomes green, temperature falls, albuminuria if 
present disappears, the spleen diminishes in size, the 
tongue becomes moist, and convalescence is rapid. £ 
It must be recollected that alpha-naphthol, which in 

* Practitioner, December, 1888, and July, 1890. 

f Boston Medical and Surgical Journal, Nos. 14 and 15,. 

1892. 

X See Yeo on the "Antiseptic Treatment of Typhoid 
Fever." 



— 55 — 

antiseptic power may slightly exceed beta-naphthol, is 
somewhat more irritating and of more disagreeable 
taste, and so should not, as a rule, be preferred to its 
congener. 

Certain salts of beta-naphthol, the salicylate and 
benzoate, I regard as highly promising remedies in 
the treatment of typhoid fever. These salts have but 
slight taste, and that aromatic and agreeable, and are 
also entirely unirritatihg in even very large doses. 
^Esthetically they are decidedly preferable to beta- 
or alpha-naphthol for internal administration. Al- 
though in their unchanged state they are without 
germicidal power, and it has been thought are less 
readily decomposed into their respective acid and 
active germicidal base than phenol salicylate (salol) 
in an alkaline medium, from the results of both clinical 
and laboratory experiment I have found both remark- 
ably efficient as intestinal antiseptics, especially beta- 
naphthol salicylate. I can, therefore, now recom- 
mend their trial, not only in typhoid fever, but in 
cholera. 

My experiments have been principally with beta- 
naphthol salicylate (betol), which has yielded excel- 
lent results in several cases of chronic diarrhoea in 
which beta-naphthol in full doses was too irritating. 
In one of these the ailment was dependent; upon in- 
testinal indigestion originated by marked HC1 hyper- 
acidity. In a number of experiments made, I found 
that, even in cases of hyperacidity of the gastric 



- 56 - 

juice, if the remedy was exhibited immediately after 
meals, its decomposition was assured, with a sali- 
cyluric response in the urine inside of an hour, in- 
dicating its ready disassociation into its components 
in the upper bowel. In a case of chronic diarrhoea 
dependent upon intestinal indigestion due to gastric 
hyperacidity, it was interesting to note that no 
beneficial result followed when its ingestion was de- 
layed from immediately after meals to three hours 
subsequently. Both betol and benzonaphthol, of 
which two I prefer the former, may be given in doses 
of twenty to forty grains several times daily, and are 
well worthy of a thorough trial in typhoid fever, as in 
cholera. Unfortunately they are much more expen- 
sive than is beta-naphthol. 

Naphthalin, which formerly received extensive 
trial in typhoid fever — by many combined with 
calomel, which was believed to increase its efficiency 
— is decidedly inferior, as an intestinal antiseptic or 
disinfectant, to the naphthols, or their salts already 
mentioned, and is moreover much more toxic than 
naphthol. It was first recommended by Rossbach, 
who believed that it exerted an abortive effect on the 
disease. His claims, however, were not supported 
by Furbringer either clinically or bacteriologically, 
though the remedy was carefully tried in 100 cases and 
administered in daily doses of from three to five 
grammes. More recently L. Wolff, of Philadelphia,* 

* Medical News, May 23, 1891. 



— 57 — 

reported a consecutive series of 100 cases treated by 
naphthol, with a mortality of about two per cent. 
Wolff looks upon the drug with great favor. He be- 
lieves that it exerted an abortive action in sixteen of 
his cases. Any intestinal antiseptic action which 
naphthalin may have, he attributes to its conversion 
into naphthol in the bowel. If naphthalin is tried, 
it may be administered in daily doses of fifteen grains 
to one drachm (one to four grammes) finely pulverized 
with coffee, or in emulsion or capsule. These latter 
should contain a small quantity of an essential oil, 
such as bergamot, to assist in concealing the disagree- 
able odor. It is important that only purified naph- 
thalin be prescribed. In an instance in my practice in 
which a druggist substituted an inferior preparation 
(commercial tar-camphor) for the former, hematuria 
and other signs of renal irritation, such as loin pain, re- 
sulted from a dose totally insufficient to cause such 
symptoms from an equivalent quantity of the pure 
drug. 

Liebermeister, Wunderlich and others claimed 
that the use of calomel in typhoid fever tended ma- 
terially to shorten the duration and lessen the inten- 
sity of the disease, and Wunderlich even believed 
that the disease might sometimes be aborted by its use. 
Liebermeister treated several hundred cases with 
calomel, usually giving three to four 8-grain doses in 
the first twenty-four hours of treatment, at an early 
period of the disease and before intestinal ulceration 



- 58 - 

was believed to have occurred. Most of his cases so 
treated seemed to do well and the fever to run a 
milder course. 

Through the influence of the teachings of Lieber- 
meister and Wunderlich, calomel has received a very- 
general trial in typhoid fever, given either in several 
large, initial doses, or in smaller amount throughout 
the course of the disease. There are none now who 
claim for it any specific effect. It is certainly with- 
out destructive influence on the typhoid germ, though 
it is inimical to ordinary faecal bacteria. However, 
because of its being a very efficient and safe laxative, 
and on account of constipation frequently being pres- 
ent in the early stage of the disease, calomel has 
come more or less into general use in typhoid fever in 
the manner recommended by Murchison — one or two 
moderate doses (two to five grains) in the first week 
before the appearance of marked diarrhoea. Thus 
used, though calomel produces free purgation, it does 
not tend subsequently to aggravate diarrhoea. As 
the opinion seems well founded that the administra- 
tion of an initial laxative dose in the early stage, 
prior to the date at which it is thought the intestinal 
lesion has advanced to ulceration, can do no harm 
and is often productive of benefit, calomel should be 
used unless another laxative has been taken by the 
patient just prior to coming under observation. 

Henry, of Philadelphia, especially favors the use 
of thymol in typhoid fever as an intestinal antiseptic. 



He recommends it in preference to all other suggested 
remedies for a similar effect. He states* that in every 
case in which he has employed the drug in an early 
stage of the disease the tongue has become rapidly 
clean and moist and has so continued; tympany, if 
present, has steadily subsided; diarrhoea has dimin- 
ished, and mental symptoms have disappeared; and 
the temperature has been favorably influenced. These 
observations by so accurate and painstaking an ob- 
server indicate that thymol may have some special 
influence for good in this disease, and it is worthy of 
extended trial. I myself have never used it. 

Apart from Henry's favorable clinical observa- 
tions, theoretically thymol is worthy of trial because 
of its having an antiseptic potency of no mean order, 
amounting to four times that of carbolic acid. It is, 
moreover, but slightly toxic, and is more or less insol- 
uble in the stomach and intestines. It may be given 
in amounts upward of forty grains daily. Henry 
rarely employs more than twenty grains daily, in 
quantities of 2Y2 grains every three hours. He pre- 
fers to administer it in gelatin-coated or in uncoated 
pills, with medicinal soap as an excipient. Water 
should be freely taken with the uncoated pill to in- 
sure its rapid passage into the stomach and thus 
obviate the unpleasant burning sensation produced 
should thymol remain in contact with faucial or oeso- 
phageal mucous membrane. 

* L. c, p. 307. 



— 6o — 

An Italian physician, Testi,* in the year follow- 
ing Dr, Henry's recommendation of thymol, reports 
results very similar to those of the latter with this 
drug in 150 cases of typhoid. 

A remedy of an order similar to thymol deserves 
brief mention — the oil of eucalyptus. The utility of 
this in typhoid fever has been especially investigated 
by Kestevan, of Brisbane, f In 220 cases in which it 
was reported used by Kestevan, many of which he 
stated had a bad beginning, there were but four 
deaths. He gave from five to ten minims of the oil 
in emulsion with mucilage every four hours. To dis- 
guise the unpalatable taste of the oil, he combined it 
with sal-volatile, spirits of chloroform, and glycerin. 
Kestevan noted that under the eucalyptus treatment 
there was a reduction in the pulse-rate, a remarkable 
lowering of temperature, a rapid clearing and moist- 
ening of the tongue; that the skin likewise becarrK 
soft and moist and the duration of the fever greatly 
shortened. A withdrawal of the eucalyptus was al- 
ways followed by a return of unfavorable symptoms. 

A mixture of carbolic acid and tincture of iodine, 
in either equal proportions or in proportions of one 
part of the former to two of the latter, has also been 
recommended for a specific effect in the treatment of 
typhoid fever, in doses of one to three drops several 
times daily. Bartholow highly lauded this combina- 

* Allg. Wien. Med. Zeitung, No. 9, 1889. 
f Practitioner \ May, 1885, April, 1887. 



— 6i — 

tion, and it is still a favorite with many. I at one 
time tried it somewhat, with apparently good results. 
Because of its ready absorption from the stomach, its 
utility, if any is possessed by it (like that of sulphur- 
ous acid, and chlorine-water), cannot, of course, be 
through any local action on the intestinal condition. 
It would be especially indicated in the more rare cases 
in which nausea and vomiting are a troublesome 
symptom. The mixture of carbolic acid and tincture 
of iodine is of much utility for its local sedative action 
on an inflamed or irritated gastric mucous membrane. 

Niemeyer and Murchison commended the use 
of sulphurous acid in typhoid fever; and Wilks of 
Ashford, and Yeo have reported quite remarkable re- 
sults with it in this disease, though at the present 
time Yeo regards chlorine-water as a preferable 
remedy. Wilks used sulphurous acid largely, with 
marked benefit, in a considerable number of cases, 
some of which were of severe type. He found that 
it allayed vomiting and purging, when present; that 
it reduced tympanites, supported the pulse, moistened 
the dry tongue, and relieved thirst. He used the acid 
in 171 cases without a death. In most of these, con- 
valescence ensued within fifteen days after commenc- 
ing treatment. In a few of the early cases he discon- 
tinued the use of the acid, as the ailment rapidly 
yielded to it; a relapse then occurred, which was 
again immediately arrested on the resumption of the 
remedy. Wilks gives the acid in doses of three to 



— 62 — 

twenty minims, according to age, every fourth hour, 
and continues it for a week, or even longer, until the 
patient complains of tasting and smelling sulphur, 
or, in the case of infants, until an odor of the gas is 
emitted from their skin and breath. For adults, 20 
minims of the sulphurous acid was mixed with an 
ounce of water and a little syrup of orange-peel, and 
given every four hours. 

Two well known practitioners in Dr. Wilks's 
neighborhood, who also testify to the invariable suc- 
cess of this remedy in their practice, long ago brought 
it to the notice of Yeo, who also used it with good 
result, but subsequently abandoned it for what he 
conceived a better remedy, chlorine-water. This, 
many years ago, was also recommended in typhoid 
fever by both Sir Thomas Watson and Murchi- 
son. Yeo soon became so much impressed with the 
virtues of chlorine-water that he abandoned search 
for other specifics and has since treated all his cases 
with this remedy. He is now as enthusiastic concern- 
ing it as at first. The following is Yeo's plan of pre- 
paring the water: " Into a 12-ounce bottle put y 2 
drachm of potash chlorate, and pour on it 40 minims 
of strong HC1; chlorine gas is at once actively lib- 
erated. Fit a cork in the mouth of the bottle; keep 
it closed until it has become filled with the greenish- 
yellow gas. Then pour water into the bottle little by 
little, closing the bottle and well shaking at each 
addition, until the bottle is filled." This forms a 



I* 



- 63 - 

solution of free CI together with some undecom- 
posed potash chlorate and HC1. He greatly prefers 
this preparation of chlorine to the liquor chlori of the 
British Pharmacopoeia. It is ndt only more pleasant 
to take, but results obtained with it are better. Yeo 
adds about half a drachm of quinine and an ounce of 
orange-peel to each twelve ounces of the solution, and 
gives an ounce every two, three, or four hours, accord- 
ing to the severity of the case. He thus gives, coin- 
cidently with the CI, 12 to 26 grains of quinine daily, 
so that his treatment is a mixed one. 

However that may be, he reports quite surpris- 
ing results with the combination. One of these is a 
remarkable cleaning of the tongue. He states that a 
dry, dirty, thickly coated tongue is scarcely ever 
encountered in a patient who has been put on this 
mixture early. Other results he has noticed are: a 
modification and sustained depression of the febrile 
temperature; the abbreviation of the average course 
of the fever; a remarkable maintenance of the phys- 
ical strength and intellectual clearness of the patient, 
with less need for stimulants; a greater power of 
assimilating food; a rapid and complete convales- 
cence. The fetor of the evacuations also usually 
disappears within twenty-four hours after initiating 
this treatment. This he naturally regards as an 
interesting and important point, inasmuch as, from 
the solubility of the chlorine, it would be supposed 
not to reach directly the lower part of the bowel. 



-64 - 

The antiseptic action which it exerts on the intes- 
tines is perhaps a systemic one through the blood, in 
which fluid Yeo believes it may neutralize some septic 
substance generated *by the typhoid bacillus, so that 
the excretions into the intestine are modified and an 
antiseptic effect on the intestinal contents is produced. 

As an indication that the active agent in these 
results is not quinine, Yeo cites a case in which, 
having deviated from his ordinary prescription, and 
writing for liquor chlori, B. P., with quinine, chloro- 
form-water was substituted for the chlorine-water, 
with no little temporary detriment. The patient had 
previously been doing well on the chlorine-water mix- 
ture, and the temperature was maintained reduced. 
Unexpectedly, however, it arose from 101.6 0 F. to 
104.4 0 F., and the stools once more became of offen- 
sive odor. A search for the cause of this untoward 
condition revealed the substitution, which was at once 
corrected, with corresponding prompt amelioration of 
the symptoms. 

It appears to Yeo that it usually takes forty-eight 
hours before the treatment by chlorine-water begins 
to notably affect the temperature. He states that no 
surprise should be felt if the temperature rises a 
degree or more during the first twenty-four hours of 
treatment. This treatment, therefore, differs greatly 
in this respect from that with the numerous anti- 
pyretic medicines now so much used. 

Quinine at one time was very generally used in 



- 65 - 

large doses in the treatment of typhoid fever, many 
fancying that it exerted some specific influence on the 
course of the disease. Its general employment fell 
into disrepute because of its indiscriminate use in 
excessive doses. It has now again become somewhat 
more of a general favorite with those who do not 
resort to the exclusive use of cold-bath treatment. 
Bouchard uses it in the treatment of typhoid fever, 
combined with naphthol and bismuth salicylate, con- 
tending that while the latter disinfect the alimentary 
canal, quinine acts as a general or systemic antiseptic, 
neutralizing the infective principle in the blood. He 
considers that its febricide action in this disease is 
largely due to its antiseptic effect. 

It is worth while to quote Bouchard's statistics 
under this treatment, which tend to support his idea of 
its utility. At the Lariboisiere Hospital, from 1854 to 
1885, 12,246 cases of typhoid fever were treated, with 
a mortality of 21.15 per cent. The recent statistics 
under this treatment for four years, 390 cases treated, 
show a mortality of but 11.75 P er cent. He states 
that his mortality amounts to only two-thirds of the 
whole mortality rate of the other cases of typhoid 
fever treated in the hospital during a period in which 
his method has been employed in his service alone 
(Yeo). 

Bouchard gives quinine in such a way that though 
the average daily amount equals only 10 grains, the 
dosage at the early part of the treatment seems ex- 

5 RRR 



— 66 — 

cessive. During the first fortnight a half-drachm is 
given in the evening, in four doses of 7% grains 
every half-hour, at intervals of three days. In the 
third week the half-drachm is reduced to 22 grains, 
and in the fourth week to 15 grains. 

Graucher adopts a similar plan in the treatment 
of typhoid fever in children, and holds that quinine 
has a specific antiseptic action. 

Yeo, in speaking of Sir Thomas Watson's advo- 
cacy of quinine in typhoid fever, remarks that when 
a remedy returns repeatedly into favor and impresses 
successive generations of physicians from time to 
time with the idea of its value and efficacy, there 
seems no doubt that this belief has foundation. He 
says that what is needed to crystallize these observa- 
tions into an established therapeutic practice is a 
central idea unchanging, because true — a generalized 
deduction from observation or experiment. This 
idea is now furnished us by the knowledge of the 
antiseptic influence of quinine. Yeo then calls atten- 
tion to the fact that Eberth has shown that quinine 
exerts a powerful antiseptic effect on the typhoid 
bacillus. Yeo has, therefore, much the same opinion 
of the utility of quinine as Bouchard, and employs it, 
as has been stated in the foregoing, in combination 
with chlorine-water. He thinks that the efficacy of 
quinine depends largely upon the mode of adminis- 
tration, and especially noticed this in giving quinine 
in pneumonia and in attacks of influenza. When he 



- 67 - 

prescribes the quinine, dissolving in citric acid and 
given in effervescence, by adding it to an alkaline 
mixture, he finds that doses of two to three grains 
exert a powerful antiseptic effect — much greater than 
that obtained by the same amount of quinine given in 
the dry state. • 

A form of specific treatment of typhoid fever 
other than the antiseptic must be now briefly referred 
to, the value of which is still sub judice. It is that by 
parenchymatous injection of diluted cultures of the 
specific typhoid bacillus, and also by the use of dead 
cultures of another bacillus, the product of the 
activity of which is unrelated to that of the bacillus 
of typhoid fever. That such a search for specific 
treatment of typhoid fever would certainly be made, 
was apparent long ago, from experiment having been 
undertaken in analogous directions with some evi- 
dence of success, and from the increasing trend of 
inquiry for immunizing and antidotal substances de- 
rived from bacteria or the product of their life 
activity. Frankel * reports treating fifty-seven cases 
of typhoid fever by parenchymatous injections of a 
sterile culture of dead typhoid bacilli previously ren- 
dered non-toxic by growing on bouillon made from 
the thymus gland of the calf. The injections were 
given in initial doses of 0.5 c.c, followed on the 



Deutsche Med. Woch., Oct. 12, 1893. 



— 68 — 



second day by i.o c.c. The second and larger injec- 
tion was attended by rise of temperature, and, in cer- 
tain of the cases, by slight or more severe rigors. 
The injections were now given on alternate days, the 
dose being increased i.o c.c. on each occasion. The 
particulars of the results and details of the method 
cannot be given here. For them the reader is re- 
ferred to the interesting paper of Frankel. It here 
suffices to say that the method may be regarded as 
promising. Under the injections, remissions in fever 
promptly occurred, soon followed by its total disap- 
pearance and by that of the constitutional symptoms 
of the disease. 

F rankers results and the knowledge that the pre- 
vious existence of certain modified infectious ailments 
creates immunity from related diseases, suggested to 
Rumpf f to try the experiment if the course of 
typhoid fever might not be favorably influenced by 
the introduction of bacterial products different from 
those generated by the specific bacillus of that dis- 
ease. He therefore began experiments with the use 
of sterile dead cultures of micro-organisms of a kind 
totally unrelated to the sort originating typhoid fever. 
After a trial of cultures of streptococci without result, 
he resorted to the use of cultures of the bacillus pyo- 
cyaneus, grown in thymus-gland bouillon. With that 
Rumpf has now treated by subcutaneous injection 



f Deutsche Med. Woch., Oct. 12, 1893. 



- 69 - 

thirty cases of typhoid fever, with results which he 
regards as only slightly less favorable than those of 
Frankel. 

The practicability and probable actual value of 
this novel method of treating typhoid fever must 
remain for some time undetermined. It is not too 
much to say that something may be hoped for it in 
the light of recent developments as to the causation 
of the infectious diseases, and their prevention and 
cure by the use of immunizing substances derived 
from micro-organisms. 

Regarding this particular plan of treating typhoid 
fever, the following is of interest, quoted from the 
Medical News of Dec. 16, 1893, which thus notes this 
method editorially: " Buchner (Munchener Med. Woch., 
1893, No. 43), in commenting upon this work, ex- 
presses his satisfaction with the results, especially with 
the conclusions of Rumpf, and points out the analogy 
between Frankel's work and the treatment of tuber- 
culosis with tuberculin. From a bacteriologic stand- 
point, typhoid fever has to be looked upon as a fight 
of several weeks' duration between the animal organ- 
ism and the typhoid bacilli in the intestines, mesen- 
teric glands, and other organs. On the part of the 
human body the war is carried on with the aid of an 
inflammatory (and febrile) reaction, an attempt being 
made, either through the activity of the leucocytes (?) 
or through germicidal substances newly formed in the 
tissues (of the nature of which we are as yet ignorant), 



— 70 — 

to bring about the destruction of the invading bacilli. 
Buchner, therefore, views the aim of these bacterial 
injections just described as an effort to render this 
'curative reaction' more intense, and thus more effec- 
tual, exactly as was that of the treatment of tubercu- 
losis with tuberculin. Here we have nothing to do 
with antitoxic influences, or with the production of im- 
munity, nor have these effects (as Rumpf has pointed 
out) essentially anything to do with 'specificity,' any 
more than have those of the tuberculin-reaction, 
as was shown for the latter two years ago by the 
fact that it can be set up by the products of bacteria 
other than tubercle bacilli. The seat of reaction is, 
however, determined by the localization of the lesions 
of the specific disease, apparently because there the 
tissue elements are already in an abnormal state of 
excitation, and can all the more easily be aroused to 
a still greater activity. Very different substances are 
capable of calling forth the reaction. We already 
know that the protein-substances contained in the 
bodies of different kinds of bacteria can give rise to 
it, and it is probable that other substances which 
cause a leukocytosis or a local inflammation can serve 
the same purpose. It will be necessary, as Buchner 
says, to determine how much, if any, of the effect 
produced by these injections of Frankel and Rumpf 
is directly dependent on the extract of thymus which 
is employed in the preparation of the bouillon, for 
experiment has shown that the extract exercises a 



7 1 

positive chemotic influence, as do the bacterial pro- 
teins themselves." 

Before discussing the treatment of special symp- 
toms and complications, the following important 
words of Broadbent bearing upon their recognition 
may be quoted with advantage: " The most careful 
watch should be kept for complications at all stages 
of the fever, but especially after the end of the second 
week. A rise of temperature must always be taken 
to have some definite significance requiring explana- 
tion. With increased frequency of respiration, it may 
be the sole indicative of the accession of pneumonia 
or pleurisy. A fall of temperature may give warning 
of haemorrhage. Retention of urine, though uncom- 
mon in typhoid as compared with typhus fever, should 
always be borne in mind, and unusual restlessness 
should at once suggest an examination of the hypo- 
gastrium. The passage of a catheter has often put an 
end to sleeplessness and exhaustion. Bed-sores ought 
never to occur, and it will conduce to their prevention 
for the medical attendant to inspect the sacral region 
and other parts where they are liable to be produced." 



TREATMENT OF SPECIAL SYMPTOMS AND 
COMPLICATIONS. 



Constipation at the outset, and prior to the stage of 
the disease at which it is believed intestinal ulceration 
is present, should be met by one or two rather good- 
sized (two- to five-grain) doses of calomel, as previ- 
ously indicated. Later, moving the bowels by simple 
enema on alternate days is preferable to the em- 
ployment of medicinal laxatives which might lead in 
turn to diarrhoea difficult of control, and to aggrava- 
tion of the intestinal ulceration. During late con- 
valescence, if constipation be the rule, an occasional 
small laxative dose (one to two drachms) of castor 
oil, or small dose of calomel (one-half to one grain), 
may be employed, or a non-griping preparation of 
cascara combined with belladonna may be used. 
Broadbent calls attention to the importance of re- 
moving rectal accumulations by enema before resort- 
ing to the use of laxatives by the mouth. 

Diarrhoea. — Careful, painstaking supervision of 
the diet of the typhoid case from the start, which 
necessitates, of course, daily inspection of the stools, 
will in most cases prevent the occurrence of excessive 
diarrhoea. It must be remembered that diarrhoea is 
in a measure conservative, and when moderate in 
amount, not exceeding three to five stools daily, 
should not be interfered with. If the number of pas- 



— 73 — 

sages is excessive, and especially if they are very 
fluid, an effort must be made to diminish their fre- 
quency and alter their character. This last can often 
not be done until some alteration in diet is brought 
about. 

Excessive use of both milk and beef-tea is a 
fruitful source of increased intestinal derangement in 
typhoid fever. Should curds appear in the stools, 
milk must either be withdrawn or, if continued, must 
be more thoroughly diluted, either with plain water 
or with an alkaline water, or it must be administered 
predigested. Beef-tea, or strong beef-broth of any 
sort, must not be given in too concentrated form, as 
the salts it contains often irritate the already hyper- 
sensitive and inflamed bowel. 

For the medicinal control of diarrhoea, some of 
the antiseptic remedies already considered may be 
used, such as beta-naphthol, especially combined with 
bismuth. The naphthol must not be used in too large 
a dose, lest it itself have an irritant action. From 
three to five grains of the re-sublimed medicinal beta- 
naphthol of Merck, finely pulverized with aromatic 
powder, and combined with five to ten grains of bis- 
muth salicylate or subnitrate, may be administered 
every third hour. A small amount of aromatic 
powder of chalk and opium (B. P.) may take the 
place of simple aromatic powder and of the bismuth. 
Or beta-naphthol salicylate (betol) may be used 
alone, in doses of ten to twenty grains every two to 



— 74 — 

four hours. This last, before mentioned in detailing 
the specific treatment of typhoid fever, is the most 
elegant and efficient of the numerous antiseptics. It 
is tasteless, non-irritant, and non-toxic, and further, 
more efficient than is salol. A new salt of naphthol, 
beta-naphthol-bismuth, will doubtless prove of much 
efficiency for the control of diarrhoea in typhoid fever, 
as well as that of infectious bowel ailments of other 
origin. Beta-naphthol-bismuth was lately described 
by Jasenski {Arch, des Ss. Biology v. ii., No. 2). It is 
a comparatively tasteless salt of naphthol, and con- 
tains 80 per cent, of bismuth oxide. It is non-toxic, 
so may be given- in large doses with safety, though 
from one to four grammes will usually be found effi- 
cient for all purposes. It is stated that this salt of 
naphthol is decomposed by both the gastric and the 
pancreatic juice. Among other drugs that may be 
used is opium, preferably in the form of MacMunn's 
Elixir; or an opium suppository combined with iodo- 
form and a small quantity of belladonna may be em- 
ployed. Pepper regards silver nitrate as the best rem- 
edy for the control of intestinal catarrh, including 
diarrhoea. Nitrate of silver, as is well known, is Pep- 
per's favorite drug in typhoid fever, irrespective of 
symptoms; he is inclined to look upon it as approach- 
ing somewhat the specific in its action upon the 
catarrhal and ulcerated lesion of the gastro-intestinal 
mucous membrane, and routinely prescribes it in all 
cases of the disease. When diarrhoea is excessive he 



— 75 — 

uses it in pill form in doses of one-fourth grain, com- 
bined with extract of opium in a similar or a less dose. 
An enema of tincture of opium (twenty to thirty drops 
in half a fluidounce of starch-water) is also efficient 
and much used for the control of diarrhoea. 

Gastric irritability is sometimes so excessive as to 
demand special medication. Attention should first 
be paid to the diet, which will usually require some 
modification. All drugs the use of which is calcu- 
lated to further disturb the system should be with- 
drawn. A light animal-broth, of the sort most agree- 
able to the patient, or peptonized milk or peptonized- 
milk gruel, is the best food used in small quantity. 
Or milk may be taken largely diluted with lime-water 
or in an effervescing alkaline water. Minute doses of 
calomel, one-twenty-fourth to one-eighth grain every 
half-hour until one to two grains are taken, are some- 
times very efficacious in controlling vomiting, and 
should be used at the outset if constipation is present. 
Equal parts of carbolic acid and tincture of iodine, in 
one-drop doses with half-ounce of dilute mint-water 
as the excipient, being still more largely diluted at 
the bedside, is often of great efficiency in controlling 
both reflex vomiting and that due to excessive gastric 
irritability. Nitroglycerin, in drop doses of the cen- 
tesimal solution, is often also singularly efficient in the 
control of vomiting in gastric catarrh, and may be of 
great use here. Another promising, and recently 
recommended, remedy is menthol. This last is best 



- 76 - 

used in 20-per-cent. solution in olive oil, of which 10 
drops are administered, made into a mass with pul- 
verized sugar at the bed-side, and ingested with a sip 
of water. This should be taken on the occurrence 
of nausea. Strontium bromide, in doses of ten to 
twenty grains, repeated every second hour, is also 
sometimes of great utility. With the last, hydro- 
cyanic acid may be combined, the whole administered 
in dill- or mint-water. Vomiting dependent upon per- 
foration and subsequent peritonitis, we can of course 
only hope to subdue by morphine, which must be 
given hypodermically. 

Management of High Temperature. — The most 
important mode of combating high temperature is 
that by cold baths, which has been considered in a 
previous portion of this book as the essential part of 
the management of the disease itself. It was there 
asserted that the cold-bath treatment, though th r 
most satisfactory to maintain the temperature within 
proper bounds, also exerted a general influence for 
good on the course of the disease so far-reaching in 
its effects, that to term it simply a method to reduce 
temperature is to notably fail to grasp its great utility 
and beneficence. Even if the strict Brand method 
cannot be carried out, the cold bath should be pre- 
ferred to the employment of an internal antipyretic. 
The plunge at a temperature of 65 0 to 70 0 F. is to be 
preferred to other modes of using water, and when 
resorted to should be strictly on the lines already fully 



— 77 — 

laid down. Energetic friction of the extremities, 
chest and back during the bath, must not be for 
gotten, to insure reaction, and the use of stimulants 
or hot meat-broth maybe resorted to afterwards as 
detailed. The pack is decidedly inferior to the 
plunge, yet may have to be resorted to in absence of 
facilities for the proper application of the latter. 
Baruch points out that "as an antipyretic, the cooling 
effect of the pack is limited to the first few minutes; 
the vessels are rapidly contracted by the shock of the 
peripheral nerves; the cool blood is sent to the in- 
terior only until the reaction is established. Now, 
however, the sheet surrounding the heated body 
rapidly absorbs its heat; there being no accession of 
cold as in the bath, the now dilated superficial ves- 
sels do not receive cooled blood to carry to the inte- 
rior, as in the cold bath. A second pack is required. 
The patient, now warm, his superficial vessels dilated 
far better than in the cold bath (with friction), is 
wrapped again in a sheet wrung out of water at 6o° F. 
The stimulating effect is pronounced; the patient is 
refreshed; the blood, cooled for a few minutes on the 
surface, rapidly diffuses its lowered temperature in 
the interior. But very soon equalization of tempera- 
ture between the body and the sheet takes place, 
which, according to experiment, requires about ten 
minutes. A third and a fourth pack must be resorted 
to, each one reducing the temperature slightly by the 
process indicated. Liebermeister has demonstrated 



- 78 - 

by actual trial that four successive packs, of ten 
minutes each, reduce the temperature only as much 
as a cold bath of ten minutes. Hence it would require 
about five or six packs, lasting over an hour, to pro- 
duce the same effect as one of our 65 ° Brand baths 
of fifteen minutes." 

For the further technique of the pack, the reader 
must consult Baruch's excellent book. Either one 
pack after another may be used as Baruch suggests, 
until the temperature is lowered as desired — the in- 
dication for the change of sheet being the degree of 
warmth communicated to the superimposed sheet and 
blanket; or the patient may be wrapped in a sheet 
wet with cold water, and the sheet then freely 
sprinkled with cold, even ice-water, thorough friction 
being used at the same time through the sheet by an 
attendant. 

When baths or the cold pack cannot, for some 
reason, be used, at least in mild cases the body may 
be frequently sponged with cold water whenever the 
temperature reaches 102 0 to 102. 5 0 F. A bladder of 
ice may be kept more or less constantly about the 
head, tied to the headboard; or Leiter tubes may be 
used to the head. Cold compresses should be kept 
upon the abdomen in all cases; the cloths of these 
should be changed as soon as they have become 
warmed by the body. 

The consensus of opinion of all careful observers 
and thinkers who have made use of the internal anti- 



— 79 — 

pyretics, since they have so freely come to us from 
Germany in recent years, is that they should be em- 
ployed as little as possible for the control of pyrexia 
of typhoid fever. There seems no doubt that these 
antipyretics have absolutely no antidotal effect upon 
the cause of the febrile rise, which is again in active 
operation within an hour after the ingestion of the 
drug. It is also certain that their use increases very 
much the tendency to cardiac failure and collapse, an 
ever-present danger in severe cases of typhoid fever, 
and that their persistent administration prolongs the 
course of the disease and renders convalescence te- 
dious. Ehrlich some years ago called attention to the 
obstinate splenic enlargement in cases in which thallin 
had been used; and the researches of Roque and 
Weil, before referred to, show that agents like anti- 
pyrin greatly diminish the excretion of the toxines of 
the disease, which, after the discontinuance of the 
antipyretic, become much increased during conva- 
lescence.* There are few now, even among tyros in 
medicine, who resort routinely to the use of the in- 
ternal antipyretics in typhoid fever. But where the 
cold bath is inadmissible, and the pack or cold spong- 
ing alone is insufficient to keep the axillary tempera- 
ture within 103 0 F., in a patient in whom the coin- 

* This effect is directly opposite to that of the cold bath 
and different from that produced by naphthol, in that naph- 
thol causes diminished excretion indirectly, by diminishing 
production, as has been stated elsewhere. 



— 8o — 



cident presence of mild cerebral or cardiac symptoms 
indicates mischief likely to result from the toxaemia 
producing the pyrexia, moderate doses of one of the 
internal antipyretics, such as acetanilid, antipyrin, 
phenacetin, or quinine, may be cautiously resorted to. 
As regards the coal-tar products especially, individual 
susceptibility must be borne in mind, as well as the 
tendency sometimes present in the latter stage of 
typhoid fever, and often in children, for a sudden 
drop of temperature to occur — a natural crisis, which, 
resulting coincidently with the employment of a few 
doses of one of these antipyretics, might cause a fall 
not outside the limit of danger.* It is better to re- 
sort to a minimum dose, which may be repeated one 
or more times should the effect upon the temperature 
not be that desired. Five grains of antipyrin, or a 
similar or even smaller dose of acetanilid or phena- 



* Musser (Transactions of the College of Physicians of 
Philadelphia, p. 33, Third Series, vol. xiv), in mentioning 
these, speaks of a danger from their use, observed in hos- 
pital patients in the middle period of the disease, to be 
borne in mind. The excitement the patient is subjected 
to attending his admission in this stage, nearly always 
produces for the first twenty-four hours in which he is in 
the wards an unusually high temperature; this rise, un- 
doubtedly the result of exhaustion and excitement attending 
removal, it would be dangerous to combat by the adminis- 
tration of antipyretic drugs. A temperature of 105 0 to 105. 5 0 
F., under these circumstances, is not unusual and should call 
rather for stimulants. 



— Si — 

cetin, is usually sufficient, especially if repeated at 
intervals of half an hour until three or four doses 
have been taken, avoiding causing too great a depres- 
sion in temperature. 

As regards the use of quinine as an antipyretic, 
although few now favor its use in the massive amounts 
advised by Leibermeister some years ago — 20 to 40 
grains, in doses of 7^ grains at intervals of ten min- 
utes — many rely upon a single dose of 10 to 15 grains 
as an antipyretic, in preference to the use of the coal- 
tar preparations. Leibermeister's method is to ad- 
minister the quinine so that the whole amount be 
ingested within an hour, and in the evening, in order 
that the maximum effect may be exerted at the time 
of the usual morning remission. For my part, though 
I occasionally use quinine as a tonic in doses of two 
to three grains, every six hours, in typhoid fever 
where marked asthenia is present and the gastric 
condition is favorable, it so often happens that this 
drug disorders the stomach and aggravates diarrhoea 
that its utility is in the majority of cases questionable. 
At least, for antipyretic effect there is little doubt that 
smaller doses of antipyrin, acetanilid and phenacetin, 
are better borne and have a more tranquillizing effect 
upon the nervous system. 

It must not be forgotten that there are some such, 
for instance, as Yeo, who regard quinine as a sys- 
temic antidote for the poison of typhoid fever, and 
believe that its antipyretic effect is exerted in this way. 

6 RRR 



These, as elsewhere stated, report striking contrasts 
from its employment, especially in combination with 
other antiseptics.* 

Nervous Symptoms. — For insomnia, sulfonal, 10 
to 15 grains, is the best remedy, administered by the 
writer's method,f thoroughly dissolved in hot water, 

* A brief note must be made of a new and apparently- 
promising mode of reducing high temperature in typhoid 
fever, a mode probably lacking the ill-effects resulting from 
the use of the internal antipyretics. It is the dermal appli- 
cation of guaiacol. Intelligence of its utility in the treat- 
ment of the pyrexia of typhoid fever, which has just been 
ascertained by Da Costa, comes too late to receive notice in 
the body of this work. Having in mind that guaiacol ap- 
plied to the skin in cases of tuberculosis, produced a decided 
effect upon fever heat, through systemic absorption, Da Costa 
was recently led to try its effects in the pyrexia of typhoid 
fever. His results, published in the Medical News of Jan- 
uary 27th, 1894, are most interesting. To this the reader is 
referred for details. Suffice it here to state that the guaiacol 
is applied by painting it upon the thoroughly washed skin of 
the abdomen, chest, or thighs. It then is slowly and gently 
rubbed in. The surface is afterward covered with lint and 
waxed paper. Da Costa's experiments were made in the 
Pennsylvania Hospital. He finds that a half-drachm is an 
average dose, though the quantity used on each occasion 
must be governed by the height of the temperature that it is 
desired to control. The effect upon the fever in the cases so 
dosed was remarkable, indicating that we have in the external 
use of guaiacol a remedy of singular efficiency and utility as 
an antipyretic in typhoid fever. Whether its effects extend 
beyond mere antipyresis, is yet to be determined. 

f Medical News, Jan. 31, 1891. 



- 8 3 - 

flavored if desired with a liqueur, and drunk while 
still in solution. It will often continue in effect for 
several nights. Or small doses of codeine {% to ]/i 
grain) may be employed; or chloral (5 to 10 grains), 
strontium bromide (15 grains), and cannabis Indica 
(Y% grain). Hyoscine hydrobromate is also useful, 
and may be administered singly or combined with a 
bromide or with chloral or codeine. 

The presence of headache necessitates quiet, a 
darkened room, and ice-bag to the occiput or vertex; 
or, locally, a lotion of menthol in alcohol or in soap 
liniment should be used. If no relief is obtained by 
these, there may be given internally small doses of 
caffeine (% to 1 grain), or cocaine grain), com- 
bined with antipyrin (3 grains); or phenacetin (3 
grains); or of antipyrin with strontium bromide (10 
grains); repeated at intervals of a half-hour until two 
or three doses are taken. A combination of bromide, 
antipyrin, and caffeine or cocaine, or of antipyrin or 
phenacetin or sodium salicylate, or a small quantity 
of caffeine, or cocaine, in effervescing draught, a some- 
what similar combination of which I have long used, 
Pepper recently advises in the American System of 
Practice. 

Delirium, somnolence, and marked restlessness, as- 
sociated as they so often are with elevation of tem- 
perature, are best combated by the use of baths, the 
sedative effect of which upon the perturbed nervous 
system of the typhoid patient is well known. As re- 



_ 8 4 - 

gards drugs: bromides, camphor, valerian, and hyos- 
cine are all beneficial. Musk, often recommended, is 
so difficult to obtain an active preparation of, that its 
use is practically out of the question. The elixir of 
the valerianate of ammonia, or preferably hyoscine 
(tI~q g ra -i n ) repeated at intervals of two hours until 
several doses are taken, may be combined with one 
of the bromides, such as potassium (15 to 30 grains), 
or preferably strontium. 

It is most important to observe the precaution 
especially urged by Pepper, that delirious patients be 
not left alone for an instant. They not only fre- 
quently endeavor to leave the bed, but in two 
instances of which I have knowledge, when not for 
the moment under surveillance, have sprung from an 
upper window to the ground, with fatal result. 
Pepper advises that before resorting to mechanical 
restraint, all the resources of kind and skilled nursing 
be first exhausted. "It may," he says, "be judicious 
to let the patient rise to a sitting posture, or sit upon 
the edge of the bed for a few minutes, after which his 
delirious restlessness may be for a time allayed and 
he will sink back on his bed in a more quiet state." 

If the patient cannot be forcelessly restrained 
from too wide excursions, he must for the time be 
confined to the bed by passing a sheet about the body 
and fastening it under the bed. — The occasional de- 
pendence of restlessness upon a distended bladder 
must always be borne in mind. 



- 8 5 - 

Excessive tympanites may have two sources of ori- 
gin: either excessive development of gas as a result 
of fermentative processes in the bowel; or less this 
than an unduly relaxed or paretic condition of the 
muscular layer of the intestine and of the abdominal 
wall, due to degeneration of the same. The second 
variety is more serious and more difficult to combat 
than the former. 

Meteorism of the kind first described should be 
met by the administration of such insoluble intestinal 
antiseptics as beta-naphthol or one of its salts, already 
spoken of in describing the antiseptic treatment of 
the disease. If it is believed that the digestive func- 
tions are markedly impaired, fermentative processes 
occurring chiefly through the presence of undigested, 
decomposing aliment, nourishment should be given 
either peptonized or followed by the use of an artifi- 
cial digestant, such as pancreatin and soda in the case 
of milk. 

Meteorism not yielding to this treatment, es- 
pecially if naphthol has been employed, may be con- 
sidered to be rather due primarily to paretic muscular 
weakness, and should be met by the use of strychnia 
in full doses (-fa to grain) every four to eight 
hours, and by the liberal use of stimulants, such as 
whisky. Turpentine by the mouth, enema, and ex- 
ternally in the form of stupes, is much lauded for the 
relief of tympany in typhoid fever, but I must confess 
that though I have often employed it, more especially 



— 86 — 

in severe types of the disease encountered in hospital 
practice, admitted at a late stage in the affection, I 
have rarely seen marked benefit result, save the tran- 
sitory effect often obtained by its use in enemas. 

Turpentine is employed largely as a matter of 
routine in this country in the treatment of typhoid 
fever, primarily through the teaching of the late 
George B. Wood, and at the present day through 
the advocacy of H. C. Wood. The elder Wood 
especially recommended its use for a specific effect 
upon the intestinal ulceration, and regarded it of the 
greatest utility in excessive meteorism accompanied 
by a dry brown tongue with sordes. 

In the limited dosage in which turpentine may be 
employed, it cannot be regarded as possessing any 
marked antiseptic effects upon the parts of the bowel, 
so remote from the stomach, in which the chief lesions 
of the disease reside. Certainly, in doses of three to 
four minims, as those who most urge it for its antiseptic 
and specific effect upon the intestinal condition most 
advise, little may be expected from it. It may be 
worth a trial, however, where the other, more rational 
means fail, provided the meteorism is unaccompanied 
by much diarrhoea, and there is marked dryness of 
the mouth and tongue with browning and glazing of 
the latter and tendency to sordes, and particularly if 
bronchial catarrh is present. It should be given in 
emulsion diluted with water, in doses of five to twenty 
minims every two or more hours. 



- 8 7 - 

Extreme distension of the colon may be tempor- 
arily relieved by enemas of turpentine or of asafoetida 
introduced through a flexible tube, carefully passed to 
some height into the bowel. Or the tube itself may 
be similarly introduced, trusting through it to assist in 
the dislodgment of flatus. 

Cold compresses to the abdomen, changed so 
soon as they become warm — a most desirable routine 
procedure in typhoid fever— are also of the greatest 
value both in preventing the development of paretic 
distension of the bowel and in removing that con- 
dition. 

Abdominal pain attending great meteorism may 
necessitate the use of an opiate for its relief. Exces- 
sive and localized pain in the abdomen is significant 
of a limited patch of peritonitis, which last may be an 
important factor in the production of the paretic con- 
dition of the bowel. 

The occurrence of general peritonitis, usually in- 
dicative of perforation, but sometimes having origin in 
extension of inflammation to the peritoneum from the 
base of deep ulcers, or in rupture of a softened mes- 
entery gland, is apt in most cases to be fatal. The 
treatment for it is that for suspected perforation: the 
maintenance of absolute rest; the withdrawal, so far as 
is possible, of all food and drink (ice alone being per- 
mitted for the satisfaction of thirst); and the adminis- 
tration of a preparation of opium, or of morphia, to 
the limit of tolerance. Cold applications to the abdo- 



— 88 — 



men must be rigorously continued; but if collapse is 
threatened from perforation, heart must now be applied 
to the extremities, and nitro-glycerin, ether, or whisky 
administered hypodermically. The bowels must be 
kept confined by the free use of opium for some days 
after all symptoms have subsided; the idea being to 
favor, by all means in our power, the formation of ad- 
hesions at the seat of perforation. 

Coeliotomy is not justifiable for suspected perfor- 
ation during the course of typhoid fever, for, apart 
from the chances of generalized peritonitis having a 
less common origin than perforation in the cases that 
recover, the bowel is in too diseased a condition for 
hope of repair after operation. In perforation occur- 
ring during convalescence the case is different; here 
an abdominal section is justifiable. 

The occurrence of intestinal hemorrhage in other 
than minute isolated bleedings which show no tendency 
toward recurrence or the production of depression, 
necessitates the early use of full doses of opium to 
check intestinal peristalsis previously favored by con- 
tact in the bowel of the freshly outpoured blood. 
Absolute rest must, of course, be enjoined — even a 
folded cloth being substituted for a bed-pan, as 
Pepper suggests. Light ice-bags must be applied to 
the abdomen, especially in the caecal region. 

There is unfortunately no internal haemostatic 
upon which we can with certainty rely, although ergot, 
lead acetate, aromatic sulphuric acid, gallic acid, and 



- 8 9 - 

oil of turpentine are all more or less highly recom- 
mended. Perhaps the best of these is turpentine, ad- 
ministered in emulsion in considerable doses. That 
which is least useful, and which, indeed, may be 
actually provocative of distinct mischief, is ergot, the 
most advocated of all remedies. Regarding the use 
of this drug in this connection I have elsewhere* re- 
marked: 

" A haemorrhage of sufficient gravity in enteric 
fever to demand a resort to specific measures to cause 
its cessation, usually emanates from an eroded vessel. 
Ergot here, as in the haematemesis of gastric ulcer — 
also commonly dependent upon the erosion of an 
artery — is not only useless, but absolutely harmful, 
since, from its constricting effects on the vessels be- 
ing limited to the arterioles and causing resistance a 
f route, when a vessel larger than an arteriole is the 
source of haemorrhage the increased blood-pressure 
results in augmentation of the bleeding. This fact, 
though of vast importance, is apparently known to 
few. It was pointed out some time ago by Dr. A. H. 
Smith, in a communication to the Medical News re- 
lating to the haematemesis of gastric ulcer. The 
principle underlying it should govern the administra- 
tion of ergot for the control of haemorrhage: to use 
in that produced by capillary oozing, to avoid in that 
resulting from rupture of a vessel larger than an 
arteriole. 



* Medical News, Jan. 23, 1892. 



— go — 

" Still another important objection to the employ- 
ment of ergot in the intestinal haemorrhage of enteric 
fever is the fact that active peristaltic movements are 
thereby produced, the effects of which would inevi- 
tably be to disturb the ulcerated bowel, to provoke 
more rapid separation of the sloughs, and to aggra- 
vate the tendency to bleeding. ,, 

Collapse following haemorrhage, of course neces- 
sitates the free employment of stimulants, of which 
the best is nitro-glycerin (two or more minims of a 
i-per-cent. solution) in a syringeful of ether, hypo- 
dermically. Strychnia should be similarly employed. 
Heat must also be applied to the extremities; and if 
loss of blood has been great, transfusion of blood, or, 
preferably, the infusion of a normal salt solution 
at blood temperature into a vein, should be prac- 
ticed. As the indications for this procedure are in 
every respect similar to those for the relief of 
the overwhelming acute anaemia succeeding gastric 
haemorrhage due to an erosion of an artery, I cannot 
do better than quote from my section on the treat- 
ment of diseases of the stomach, in Hare's System of 
Therapeutics (vol. ii, p. 951), some remarks I there 
made concerning this subject: "Transfusion is indi- 
cated immediately after the occurrence of haemate- 
mesis only where it seems probable that the patient 
will succumb from the failure of circulation, experi- 
ence having shown that the increased vascular pressure 
resulting from transfusion is likely to occasion anew 



— gi — 

and, perhaps, fatal haemorrhage by leading to the dis- 
lodgment of the thrombus blocking the open vessel. 
For this reason, the imminence of a fatal termination 
demanding some such interference, the risk must be 
taken, although only the smallest amount of fluid 
should be introduced capable of tiding over the 
dangerous period, and this must be injected very 
slowly under low pressure. These precautions are 
less necessary if transfusion is demanded because of 
the acute anaemia a few days subsequent to the 
haemorrhage, when its reccurrence seems unlikely; 
here a larger amount may be introduced with but 
little risk.* In either event, if transfusion is de- 
manded, the infusion into a vein of a saline solution 
should be preferred to the introduction of blood. 
The latter, in recent years, has been almost entirely 
replaced by the former, saline solutions practically 
fulfilling better than blood all the conditions, physical 
and haemogenic, to meet which transfusion is under- 
taken, besides being far superior and easier of appli- 
cation. A ^-per-cent. solution of common salt — 
about a drachm to the pint — is the most convenient. 
Not over three-quarters of a pint should be intro- 
duced at first. When a recurrence of the haemor- 
rhage is feared, more can be used later should the 
urgency of the symptoms demand it. These solu- 

* The only risk then being perforation by the suddenly 
raised pressure if a diseased vessel in the ulcer is on the 
point of rupture. 



— 9 2 — 

tions should be made with boiled, preferably boiled- 
distilled, water. It must be of the body temperature 
and is readily introduced, all that is required being a 
small glass cannula, a piece of rubber tubing, and a 
funnel. When time admits of it, the fluid may be in- 
jected into the cellular tissue between the scapulae in 
place of a vein. The resulting benefit would be as 
great, though not so promptly produced, and the dan- 
ger, that of sudden raising of vascular tension, would 
be largely obviated." 

Epistaxis is occasionally a troublesome complica- 
tion in typhoid fever. Usually, however, it is readily 
controlled by ice compresses to the intercilium and 
bridge of the nose and to the nucha; by the injection 
of iced salt-water, or lemon- juice, or dilute vinegar, 
or a weak solution of tannin or of tincture of iron, 
into the nostrils. Remedies by the mouth are of but 
little avail, so that if the above or analagous measure 
fail it will be necessary to plug the posterior nares. 

Cardiac weakness is to be met by the free, though 
judicious, employment of whisky, and by the use of 
strychnia, digitalis, or strophanthus. Strychnia may 
be resorted to, as may whisky, so soon as evidence 
of cardiac weakness begins to appear, indicated by 
tonelessness in the first sound at the apex. Whether 
the condition then, or later, be one of mere adynamia 
from over-fatigue, or arise from actual granular de- 
generation of the cardiac muscle fibres, the same 
remedies are indicated, save that greater caution in 



— 93 — 

the second case is required with the use of digitalis, 
in any event only to be added to our therapy of 
whisky and strychnia as a last resort. Strychnia 
may be given at first in doses of grain every eight 
hours, but this amount may have to be increased to 
jig- grain, or even ^ grain, every six hours, on the 
appearance of great feebleness or the extinction of 
the first sound. Digitalis is of little utility, and may 
indeed be considered a dangerous remedy, at least in 
the large doses often given, should considerable de- 
generation of the cardiac muscle fibre be suspected. 
When feebleness of action is thought to be rather the 
result of cardiac muscle fatigue, digitalis may be re- 
sorted to in moderate doses (5 to 20 drops) every six 
hours, but here its use is scarcely necessary with the 
employment of strychnia and whisky. The alkaloid 
caffeine (one to five grains) or its citrate (two to ten 
grains) is superior and a more efficient remedy than 
is digitalis, and may be administered with strychnia. 
For sudden cardiac failure, nitro-glycerin (i-per-cent. 
solution, two to four drops), in alcohol or ether, may 
be given hypodermically, and infusion into a vein 
of one or more pints of a warm saline solution prac- 
ticed. 

To assist in the avoidance of hypostatic congestion 
of the lungs, it is important not to permit the patient 
to lie too long in one position, especially upon the 
back. On its occurrence, counter-irritation to the 
chest as in actual pneumonia, or in extensive, severe 



— 94 — 

bronchitis, or in pleurisy— not infrequent complications 
of typhoid fever— should be resorted to. Mustard 
plasters or, better, turpentine stupes may be applied. 
If pain is present, hot poultices are useful; these must 
not be changed too frequently, and should be cov- 
ered with oiled silk. The application of dry or even 
a few wet cups to the posterior surface of the chest 
may be required for the relief of pain or for the re- 
moval of extensive dullness, whether indicative of 
congestion or of actual inflammation. Turpentine is 
useful in pulmonary complications, as is terebene 
(five minims in capsule or emulsion every third hour), 
and other stimulating expectorants ordinarily used in 
these conditions irrespective of underlying cause. In 
catarrhal bronchitis or in pneumonia, ammonium car- 
bonate may be used unless contra-indicated by diar- 
rhoea; it is preferably administered in spirits of men- 
derius. Strychnia and quinine may also be required. 
The occurrence of congestion of the kidneys, or of 
nephritis, necessitates the application of dry cups or 
of poultices to the loins, and, should the urine be 
markedly diminished in quantity, the use of a saline 
diuretic, such as cream of tartar, provided it does not 
aggravate diarrhoea. 

Parotitis may be avoided by careful attention to 
cleansing the mouth with a mild antiseptic solution, 
such as very weak potash-permanganate wash, or one of 
hydrogen peroxide. Boro-glyceride is of utility if 
stomatitis exists. A mouth-wash of potassium chlor- 



— 95 — 

ate is also of use. Parotitis occurring is very apt to 
proceed to suppuration. It must then be managed on 
surgical lines. The application of counter-irritation 
externally, such as equal parts of tincture of iodine 
and of alcohol, is of value in aborting the swelling. 
If suppuration seems imminent, hot poultices should 
be applied, followed by a free incision should the 
presence of pus later be suspected. 

Venous thrombosis of one of the lower extremities, 
more commonly the left, is not infrequently en- 
countered in the later stage of a protracted case of 
typhoid fever, or more often during convalescence it- 
self. It is due to circulatory debility, and may be 
guarded against by the steady use of stimulants and 
cardiac tonics during convalescence, should the first 
sound of the heart continue enfeebled and the pulse 
show much diminished blood-pressure. Then either 
strychnia, caffeine, digitalis, strophanthus or cactus 
grandiflorus may be used, one, or both of the first 
two, alone or in combination with one of the second 
group. On thrombosis supervening, it should be 
treated by absolute rest of the leg and its elevation 
on soft pillows. In the early stage, friction of the 
limb should on no account be practiced, because of 
the danger of detachment of a portion of the clot. 
Tincture of iodine should be painted along the line of 
the course of the affected vein, or, if there be much 
pain, hot fomentations may be first used. The limb 
should then be wrapped in absorbent cotton secured 



- 96 - 

by a broad bandage. A flannel bandage may be used 
instead of the absorbent cotton and muslin bandage, 
should pain and tenderness not be decided. When 
these lessen, mercurial-belladonna ointment may be 
applied, the bandage being continued to furnish sup- 
port. Pepper recommends an ointment of ichthyol 
and lanolin, of each 2 drachms, compound iodine oint- 
ment y 2 ounce, petroleum up to 1% ounces. Later, 
on the disappearance of pain and marked subsidence 
of swelling, an elastic stocking should be worn to 
furnish support to the weakened vessel. 

The treatment of bed-sores has been considered in 
detailing the general management of a case of typhoid 
fever, so will not again be dwelt upon here. 

No mention has been made in the preceding por- 
tion of the book of the use of mineral acids, so gen- 
erally employed some years ago in the treatment of 
typhoid fever before antiseptic remedies had come 
into vogue. The only mineral acid that can ever be 
indicated in this disease is HC1, the use of which is 
less as a medicament than as a digestant. In all pro- 
nounced cases of the specific fevers, the secretion of 
hydrochloric acid in the gastric juice is markedly 
diminished. In consequence of this, such albumin- 
oids as may be administered are but imperfectly pep- 
tonized in the stomach, unless peptonization be favored 
by the administration of such an agent as HC1. The 
use of this acid may, therefore, be of much utility, 



— 97 — 

though it finds its special indication in convalescence, 
when more solid albuminoid aliment is craved and 
needed than the ability of the stomach to readily dis- 
pose of permits. During the fever, with a diet of milk 
or meat-broth, unless the latter contains considerable 
albuminoid material, HC1 is not especially indicated 
as a digestant. For the digestion of milk the use of 
pancreatin and soda is preferable, while acid taken 
too near the time of milk feeding may interfere with 
the digestion of the milk by favoring the intra-gastric 
formation of too large coagula. 

Though HC1, in common with other of the min- 
eral acids, is one of the best disinfectants of the 
typhoid and other pathogenic bacteria, among which 
is prominently the cholera spirillum, and though its 
presence in the gastric juice in the normal percent- 
age in those with healthy stomachs prevents many 
(in a manner easily understood) from developing 
typhoid fever who otherwise would, the administra- 
tion of this acid after typhoid fever has developed, 
with the expectation of its having any germicidal in- 
fluence on the parts of the bowel affected so remote 
as the ileum, is, of course, absolute nonsense. 

A few words yet remain to be said regarding the 
treatment of the stage of convalescence of typhoid 
fever. The diet in this stage has already been dis- 
cussed. It cannot be too strongly urged that solid 
food be not allowed too early, however well the pa- 
tient be doing and however much appetite may be 

7 RRR 



- 98 - 

felt. It is a safe rule, admitting of few exceptions, to 
neither allow the patient to sit up, out of bed, nor to 
allow solid aliment, until ten days after fever has dis- 
appeared. One exception to be borne in mind is that 
connected with what has aptly been styled the " bed- 
fever" phase of typhoid fever. This is one to which 
Da Costa has particularly called attention. 

This " bed-fever" was recently referred to by 
Musser (/. ^.), as follows: " There is a class of cases 
in which the morbid process has terminated, but — on 
account of the exhaustion, or the long continuance in 
bed, or the limited diet — the temperature keeps up or 
even continues to rise. Such a case was under my 
care last year. These have been spoken of as cases 
of bed-fever. In these the administration of an anti- 
pyretic would not have the desired effect. In these 
cases the fever is due to exhaustion, lack of food, and 
long continuance in bed. The use of stimulants, solid 
food, and getting the patient out of bed, brings the 
temperature to normal." 

Apart from the cases of " bed-fever" — which are 
most likely to be encountered should the attack have 
been a protracted and a severe one — caution is at first 
necessary in the administration of solid food and in 
allowing the patient to get about. Should the case 
otherwise proceed favorably and yet the temperature 
be maintained, or even rise higher, on what has been 
a low diet, without obvious cause for the febrile ex- 
acerbation, its dependence upon exhaustion must be 
borne in mind, and treated accordingly. 



— 99 — 

In addition to the bed-fever of convalescence, 
the occurrence of the febris carnis, or what Henry 
prefers to call the febris cibi, occurring after meat or 
sometimes after any solid aliment, must be borne in 
mind, and should be met by the administration of 
digestants with the food taken, as has been before 
detailed. 

Finally, in closing this resume' of the treatment 
of typhoid fever, a caution is necessary as to the abso- 
lute inutility of routine, objectless drug-prescribing. 
The danger of this cannot be too much kept in view. 
With those treating their first case of typhoid fever 
the tendency is to desire to do too much — in intention 
a laudable enough ambition, but one in actuality 
often provocative of great and irreparable evil to the 
patient. Whatever drugs are employed should be 
with the single idea of obtaining a specific result, it 
being at all times remembered that- certain grave 
dangers await on over-medication; among which 
especially are those related to disturbing the already 
impaired digestive function and aggravating the gas- 
trointestinal catarrh, present as part of the disease; 
of interfering with necessary rest and food-adminis- 
tration by constant dosing; and of losing benefit by 
habituation which might be obtained when such drugs 
are rationally indicated later, as may be the case with 
quinine, with stimulants, and with many other such 
adjuvants to treatment often too freely and too early 
used in typhoid fever. 



INDEX. 



Page 

A. 

Abdominal pain 87 

Acids, mineral, uses of, 61, 96- 97 

Alcohol, internal use of 23 

Antiseptic treatment 49- 67 

Antipyretics — coal-tar 81 

B. 

Baker, reference to 7 

Baruch, S., reference to 28- 4S 

Baths, Brand method of 28- 48 

prolonged warm 46 

graduated, of Ziemssen 46 

statistics of use of 30, 32 

technique of 36- 40 

Bed sores .14- 15 

Beef jelly 2c- 21 

Bismuth — beta-naphthol 74 

Brand's method of baths 2S- 48 

Broadbent, reference to 22, 71 

C. 

Calomel 57- 59 

Carbolic acid with tincture of iodine 60- 61 

Cardiac weakness , . 92 

Chlorine- water . 61- 64 

Collapse 90 

Constipation 72 

Convalescence, diet in 25- 26 



102 

Page 

D. 

Da Costa, J. C, reference to 82, 98 

Delirium 83 

Diarrhoea 72 

Diet in convalescence 25- 26 

— febrile 16- 23 

Disinfection of faeces . . 9- 11 

— general .11-12 

E. 

Epistaxis 92 

Eucalyptus, oil of 60 

F. 

Filters, water S 

G. 

Gastric irritability 75 

Glenard, reference to 36 

Guaiacol, external use of as an antipyretic 82 

H. 

Headache 83 

Henry, F. P., reference to -9, 59, 99 

I. 

Intestinal haemorrhage 88- 91 

Iodine, tincture of, with carbolic acid 60- 61 

L. 

Lungs, hypostatic congestion of 94 

M. 

Marston, reference to + 13 

Meat, cold infusion of 20 

beef -jelly 20- 21 

Milk, use of 16- 19 

Musser, J. H., reference to .80- 98 



— io 3 — 



Page 
N. 

Naphthaline 56 

Naphthol-a: 54 

Naphthol-/? 51 et seq., 73 

benzoate 55- 56 

bismuth 74 

salicylate 55- 56 

Naphthol, "hydro-," so-called , 51 

Nervous symptoms 82- 84 

P. 

Parotitis 94 

Pepper, W., reference to . . 31 

Perforation of bowel 88 

Peritonitis 87 

Pettenkofer, reference to , 6 

PropTiyiaxis, general and special 1- 9 

Plymouth, epidemic of 4 

Pyrexia, management of 76- 82 

Q. 

Quinine 64-67, 81 

R. 

Restlessness , 8£ 

S. 

Somnolence 83 

Specific treatment . . 67- 71 

Stomatitis 15 

Strychnia 93- 95 

Sulfonal.... 82 

Sulphurous acid 67 

T. 

Turpentine . . ... 86 

Thrombosis, venous. 95 



— 104 — 

Page 

Thymol 59- 60 

Tympanites 85- 87 

U. 

Uro-toxic coefficient, effects ot various methods of treat- 
ment on the 34, 79 

W. 

Wilson, J. C, reference to 27 

Wolff, L., reference to 56 



THE NEW METHOD 



ADMINISTRATION 



TOXIC MEDICAMENTS. 



Dilirrjal 
Tablet 



The principle of this new method of Diurnal 
Medication consist s in dividing the FULL DAILY 
DOSE into 12 small eqnul doses, one of which is 
to be administered every two hours. 



Trittirates. 



It is almost impossible for the practitioner to have at finger's 
end the ordinary minimum and maximum dose of each alkaloid, 
glucoside and similar active principles. 
"AS AN ILLUSTRATION," sn ts dr. e. trouette, 

" TAKE THE EXAMPLE OF DIGITALINt 



"At the moment of prescribing this substance, 
on.e cannot recall exactly the maximum dose in 
milligrammes which may be given to an adult in 
24 hours; one's memory must be very trustworthy 
to justify the prescription of a dose of \% milli- 
grammes; and it is, besides, necessary that chloro- 
formic amorphous digitalin of the Codex be 
specified, for there are other digitalins— the 
crystallized digitalin of the Codex, for example, 
which may not be prescribed without danger in a 
dose beyond one milligramme. Adding to this 
the fact that, if the physician specifies nothing, 
the pharmacist must supply the chlorofbrmic 
amorphous digitalin of the Codex, what, then, 
will be the result? Fearing to prescribe a toxic 
dose, we risk the giving of a quantity inade- 
quate to the purpose in view. 

"All physicians are aware that, in order to 
obtain a rapid and energetic action, it is often 
necessary to skirt the boundaries of toxicity. A 
physician cannot possibly, however, have access 
to his formulary every time he is called upon to 
prescribe a dangerous medicament; the same 
hesitation arises at each prescription of a very 
active substance, unless he confines himself to 
the use of several drugs comprising his daily 
routine. 

"With this Diurnule method all dangerous 
medicaments are so divided that, however toxic. 



the maximum dose to be given to an adult in 24 
hours shall be exactly divided into 12 doses. 
For example, the maximum dose of chloroformic 
amorphous digitalin of the Codex being \ % milli- 
grammes, the 12 Diurnules together will contain 
13^ milligrammes. For crystallized digitalin of 
the Codex, of which the maximum dose in 24 
hours is one milligramme, each Diurnule should 
contain one-twelfth of one milligramme, in such 
manner that, if the physician wishes to prescribe 
the maximum dose to be divided amongst the 24 
hours, he will prescribe one Diurnule every 2 
hours, or two Diurnules every 4 hours, or three 
Diurnules every 6 hours, etc. If it be desired at 
the outset to give the maximum dose, in certain 
urgent cases which the physician will alone be 
able to judge, according to the nature of the 
patient or o~f the malady, the 12 Diurnules may 
be prescribed in a single dose. 

"There will thus be no inconvenience arising 
from the voluntary or involuntary substitution of 
one digitalin for another; the dosage of each 
being in proportion to its activity, and consisting 
Of . one-twelfth the maximum dose, which will 
always represent the same action. 

"The physician will no longer have to exert, 
his memory to recall the maximum dose of such 
and such a medicament: he will have to remem- 
ber only the figure 12 — the duodecimal." 



We should be pleased to receive your request for our literature 
upon this subject, and for samples of both Diurnules and Diur- 
nal Tablet Triturates. 



PARKE, DAVIS & CO., 



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IN EXPLANATION OF 

The Physician's Leisure Library. 



This series has been universally commended by the medical press and profes- 
sion; it represents a new era in the publication of medical books. 

In the belief that these short practical treatises, prepared by well known 
authors, containing the gist of what they had to say regarding the treatment of 
diseases commonly met with and of which they had made a special study, sold at a 
small price, would be welcomed by the majority of the profession, this form of pub- 
lication was undertaken. 

The books are amply illustrated, and issued in attractive form in durable paper 
covers, and in cloth. 



PHYSICIAN'S LEISURE LIBRARY 

PRICE! PAPER, 25 CTS, PER COPY, $2,50 PER SET; CLOTH, 50 CTS, PER COPY, 
$5.00 PER SET. 



SERIES I. 



Inhalers. Inhalations and Inhalants. 

By Beverley Robinson, M.D. 
The Use of Electricity in the Removal of 
Superfluous Hair and the Treatment of 
Various Facial Blemishes. 

By Geo. Henry Fox, M.D. 
New Medications, Vol. I. 

By Dujardin-Beaumetz, M.D. 
New Medications, Vol, II. 

By Dujardin-Beaumetz, M.D. 
The Modern Treatment of Ear Diseases. 

By Samuel Sexton, M.D. 
The Modern Treatment of Eczema. 

By Henry G. Piffard, M.D. 



Antiseptic Midwifery. 

By Henry J. Garrigues, M.D. 
On the Determination of the Necessity for 
Wearing Glasses. 

By D. B. St. John Roosa, M.D. 
The Physiological, Pathological and Ther- 
apeutic Effects of Compressed Air. 

By Andrew H. Smith, M.D. 
GranularLids and ContagiousOphthalmia. 

By W. F. Mittendorf, M.D. 
Practical Bacteriology. 

By Thomas E. Satterthwaite, M.D. 
Pregnancy, Parturition, the Puerperal 
State, and their Complications. 

By Paul F. Munde, M.D. 



The Diagnosis and Treatment of Haem- 
orrhoids. 

By Chas. B. Kelsey, M.D. 
Diseases of the Heart, Vol. I. 

By Dujardin-Beaumetz, M.D. 

Diseases of the Heart, Vol. II. 
By Dujardin-Beaumetz, M.D. 

The Modern Treatment of Diarrhoea and 
Dysentery. 

By A. B. Palmer, M.D. 
Intestinal Diseases of Children, Vol. I. 

By A. Jacobi, M.D. 
Intestinal Diseases of Children, Vol. II. 

By A. Jacobi, M.D. 



S II. 

The Modern Treatment of Headaches. 
By Allan McLane Hamilton, M.D. 

The Modern Treatment of Pleurisy and 
Pneumonia. 

By G. M. Garland, M.D. 

Diseases of the Male Urethra. 

By Fessenden N. Otis, M.D. 
The Disorders of Menstruation. 

By Edward W. Jenks, M.D. 

The Infectious Diseases, Vol. I. 
By Karl Liebermeister. 

The Infectious Diseases, Vol. II. 
By Karl Liebermeister. 



SERIES III. 



Abdominal Surgery. 

By Hal C. Wyman, M.D. 
Diseases of the Liver. 

By feujardin-Beaumetz, M.D. 
Hysteria and Epilepsy. 

By J. Leonard Corning, M.D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M.D. 

The Theory and Practice of the Ophthal 
moscope. 

By J. Herbert Claiborne, Jr., M.D. 

Modern Treatment of Bright's Disease. 
By Alfred L. Loomis, M.D. 



Clinical Lectures on Certain Diseases of 
the Nervous System, 

By Prof. J. M. Charcot, M.D. 

The Radical Cure of Hernia. 

By Henry O. Marcy, A.M., M.D., 
LL.D. 
Spinal Irritation. 

By William A. Hammond, M.D. 
Dyspepsia. 

By Frank Woodbury, M.D. 
The Treatment of the Morphia Habit. 

By Erlenmeyer. 
The Etiology, Diagnosis and Therapy of 
Tuberculosis. 

By Prof. H. von Ziemssen. 



SERIES IM. 



Nervous Syphilis. 

By H. C. Wood, M.D. 
Education and Culture as correlated to 
the Health and Diseases of Women. 

By A. J. C. Skene, M.D. 
Diabetes. 

By A. H. Smith, M.D. 
A Treatise on Fractures. 

By Armand Despres, M.D. 
Some Major and Minor Fallacies concern- 
ing Syphilis. 

By E. L. Keyes, M.D. 
Hypodermic Medication. 

By Bourneviile and Bricon. 



Practical Points in the Management of 
Diseases of Children. 

By I. N. Love, M.D. 
Neuralgia. 

By E. P. Hurd, M.D. 
Rheumatism and Gout. 

By F. Le Roy Satterlee, M.D. 
Electricity, Its Application in Medicine. 

By Wellington Adams, M.D. [Vol.1.] 
Electricity, Its Application in Medicine. 

By Wellington Adams, M.D. [Vol.IIJ 

Auscultation and Percussion. 

By Frederick C. Shattuck, M.D. 



SER 

Taking Cold. 

By F. H. Bosworth, M.D. 

Practical Notes on Urinary Analysis. 
By William B. Canfield, M.D. 

Practical Intestinal Surgery. Vol. I. 

By F. B. Robinson, M.D. 
Practical Intestinal Surgery. Vol. II. 

By F. B. Robinson, M.D. 

Lectures on Tumors. 

By John B. Hamilton, M.D., LL.D. 

Pulmonary Consumption, a Nervous Dis- 
ease. 

By Thomas J . Mays, M.D. 



S V. 

Artificial Anaesthetics and Anaesthesia. 
By DeForest Willard, M.D., and Dr. 
Lewi H. Adler, Jr. 

Lessons in the Diagnosis and Treatment 
of Eye Diseases. 

By Casey A. Wood, M.D. 
The Modern Treatment of Hip Disease. 

By Charles F. Stillman, M.D. 
Diseases of the Bladder and Prostate. 

By Hal C. Wyman, M.D. 
Cancer. 

By Daniel Lewis, M.D. 
Insomnia and Hypnotics. 

By Germain See. 

[Translated by E. P. Hurd, M.D.] 



SERIES VI. 



The Uses of Water in Modern Medicine. 
By Simon Baruch, M.D. Vol. I . 

The Uses of Water in Modern Medicine 
By Simon Baruch, M.D. Vol. II. 

The Electro-Therapeutics of Gynaecol- 
ogy. Vol. I. 
By A. H.Goelet, M.D. 

The Electro-Therapeutics of Gynaecol- 
ogy. Vol. II. 
By A. H. Goelet, M.D. 

Cerebral Meningitis. 

By Martin W. Barr, M.D. 

Contributions of Physicians to English 
and American Literature. 
By Robert C. Kenner, M.D. 



Gonorrhoea and Its Treatmen 
By G. Frank Lydston, M.D. 

Acne and Alopecia. 

By L. Duncan Bulkley, M.D. 

Fissure of Lthe Anus and Fistula in Ano. 
By Dr. Lewis H. Adler, Jr. 

The Surgical Anatomy and Surgery of 
the Ear. 

By Albert H. Tuttle, M.D., S.B. 

Recent Developments in Massage. 
By Douglas Graham, M.D 

Sexual Weakness and Impotence 
By Edward Martin, M.D. 



SERIES VII. 



Appendicitis and Perityphlitis. 

By Charles Talamon, M.D. 
Cholera. Vol. I. 
Cholera. Vol. II. 

By G. Archie Stockwell, M.D.,F.Z.S. 

Electro-Therapeutics of Neurasthenia. 

By W. F. Robinson, M.D. 

Treatment of Sterility in the Woman. 

By Dr. De Sinety. 

Bacterial Poisons. 

By N. Gamaleia, M.D. 



The Modern Climatic Treatment of In- 
valids with Pulmonary Consumption in 
Southern California. 

By P. C. Remondino, M.D. 
Antiseptic Therapeutics. Vol. I. 
Antiseptic Therapeutics. Vol. n. 

By E. Trouessart, M.D. 
Treatment of Typhoid Fever. 

By D. D. Stewart, M.D. 
Whooping Cough. Vol. I. 
Whooping Cough. Vol. II. 
By H. Richardiere, M.D. 

[Translated by Joseph Helfman.] 



GEORGE S. DAVIS, Publisher, 

T>. O. Sox &70 33etroit, "Lviticli.. 



BOOKS BY LEADING AUTHORS. 



A PRIMER OF PSYCHOLOGY AND MENTAL DISEASE. .$ i.oo 
By Dr. C. B. Burr. 

Part I is devoted to the study of the faculties of the normal mind, and these 
are plainly and clearly set forth. Part II is devoted to mental diseases, 
causes and forms of insanity being discussed in accordance with an orig- 
inal plan of the author's. Part III deals with the management of cases 
of insanity. 

REACTIONS 2.00 

By F. A. Fliickiger, Ph.D., M.D. 

A Selection of Organic Chemical Preparations Important to Pharmacy in re- 
gard to their Behavior to Commonly Used Reagents. Translated, revised 
and enlarged by J. B. Nagelvoort, analytical chemist to the Pharm.-Chem. 
Laboratory of Parke, Davis & Co. Authorized English edition. 

TABLES FOR DOCTOR AND DRUGGIST 2.00 

Compiled by Eli H. Long, M.D. 

Comprising Tables of Solubilities, Reactions and Incompatibles, Doses and 
Uses of Medicines, Specific Gravity, Poisons and Antidotes, Thermomet- 
ric Equivalents, and The Metric System. SECOND EDITION— En- 
larged and Revised. 

THE PHARMACOLOGY OF THE NEWER MATERIA 
MEDICA— 

Price, postpaid, in cloth 3.00 

Price, postpaid, in sheep 3«50 

THE PRINCIPLES AND PRACTICE OF BANDAGING.... 3.00 
By Gwilym G. Davis, M.D., Universities of Pennsylvania 
and Gottingen. 

The most modern and complete work on bandaging ever issued. Contains 
172 illustrations, prepared from sketches especially made for this book by 
the author, printed from 23 plates on separate pages. The book is hand- 
somely printed on superior quality of paper, with wide margin, and taste- 
fully bound in red cloth. j 

SEXUAL IMPOTENCE IN MALE AND FEMALE (3d Edition). 3.00 
By Wm. A. Hammond, M.D. 

Probably more unhappiness is caused by sexual impotence than by any other 
disease that affects mankind. Dr. Hammond discusses Causes, Symp- 
toms and Treatment. 

CLINICAL THERAPEUTICS 4.00 

By Dujardin-Beaumetz, M.D. 

Dujardin-Beaumetz is easily chief in the field of original therapeutic research 
and in fertility of therapeutic suggestion. This treatise of 491 pages 
comprises his lectures on the Treatment of Nervous Diseases, General 
Diseases, and Fevers. 



PHYSICIANS' PERFECT VISITING LIST $ 1.50 

By G. Archie Stockwell, M.D. 

Physicians are generally admitted to be exceedingly poor financiers. There is 
probably no class of professional men who realize so little financially from 
their labors. One cause of this is negligence in keeping an account of their 
work. This call or visiting list has been constructed to enable physicians 
more easily to keep an accurate record of their services. It is arranged 
for perpetual use, and every physician should avail himself of this ready 
and simple method of keeping his accounts on a business basis. 

PALATABLE PRESCRIBING (Third Edition). 1 .00 

By B. W. Palmer, A.M., M.D. 

This book contains over 600 favorite formulas of the most eminent medical 
authorities, culled from their published writings and private records, and 
embraces a resume of the most eligible preparations for the administration 
of the more recent additions to the materia medica. 

A NEW TREATMENT OF CHRONIC METRITIS. 50 

By Dr. Georges Apostoli. 

This book of no pages, illustrated with cuts of apparatus, presents the details 
of Apostolus treatment by intra-uterine Chemical Galvano-Cauterizations 
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SANITARY SUGGESTIONS (Paper) 25 

By B. W. Palmer, M.D. 

FORMULA FOR THROAT AND LUNG DISEASES 25 

By E. L. Shurly, M.D. 



These are formulae which Dr. Shurly employs in hospital and private practice, 
and which he has published at the solicitation of his students. 

UNUSUAL BARGAIN! 

The following three booJcs will be sold, for a limited time, at half their 
regular price. Prices quoted are strictly net cash with order. 



UNTOWARD EFFECTS OF DRUGS $ 1.00 

By L. Lewin, M.D. 

MICROSCOPICAL DIAGNOSIS 1.50 

By Chas. H. Stowell, M.S. 

SELECT EXTRA-TROPICAL PLANTS 1.50 

By Baron Ferd. von Mueller. 



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